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CAP 715

An Introduction to Aircraft Maintenance

Engineering Human Factors for JAR 66
CAP 715

An Introduction to Aircraft Maintenance

Engineering Human Factors for JAR 66

Important Note

The CAA has made many of the documents that it publishes available electronically (in addition to
traditional printed format). Where practical, the opportunity has been taken to incorporate a clearer
revised appearance to the documents. Any significant changes to the content of this document will be
shown in the Explanatory Note. If no such changes are indicated the material contained in this
document, although different in appearance to the previously printed version, is unchanged. Further
information about these changes and the latest version of documents can be found at

22 January 2002
CAP 715 An Introduction to Aircraft Maintenance Engineering Human Factors for JAR 66

© Civil Aviation Authority 2002

ISBN 0 86039 834 X

First edition 22 January 2002

Enquiries regarding the content of this publication should be addressed to:

Human Factors, Aerodrome, Air Traffic and Licensing Standards Division, Safety Regulation Group, Civil
Aviation Authority, Aviation House, Gatwick Airport South, West Sussex, RH6 0YR

Printed and distributed by: Documedia Solutions Ltd, 37 Windsor Street, Cheltenham, Glos., GL52 2DG.
CAP 715 An Introduction to Aircraft Maintenance Engineering Human Factors for JAR 66

List of Effective Pages

Chapter Page Date Chapter Page Date

iii 22 January 2002 Chapter 3 6 22 January 2002 Chapter 6 2 22 January 2002

iv 22 January 2002 Chapter 3 7 22 January 2002 Chapter 6 3 22 January 2002
v 22 January 2002 Chapter 3 8 22 January 2002 Chapter 6 4 22 January 2002
vi 22 January 2002 Chapter 3 9 22 January 2002 Chapter 6 5 22 January 2002
vii 22 January 2002 Chapter 3 10 22 January 2002 Chapter 6 6 22 January 2002
viii 22 January 2002 Chapter 3 11 22 January 2002 Chapter 6 7 22 January 2002
ix 22 January 2002 Chapter 3 12 22 January 2002 Chapter 6 8 22 January 2002
x 22 January 2002 Chapter 3 13 22 January 2002 Chapter 7 1 22 January 2002
xi 22 January 2002 Chapter 3 14 22 January 2002 Chapter 7 2 22 January 2002
xii 22 January 2002 Chapter 3 15 22 January 2002 Chapter 7 3 22 January 2002
Chapter 1 1 22 January 2002 Chapter 3 16 22 January 2002 Chapter 7 4 22 January 2002
Chapter 1 2 22 January 2002 Chapter 3 17 22 January 2002 Chapter 7 5 22 January 2002
Chapter 1 3 22 January 2002 Chapter 3 18 22 January 2002 Chapter 7 6 22 January 2002
Chapter 1 4 22 January 2002 Chapter 3 19 22 January 2002 Chapter 7 7 22 January 2002
Chapter 1 5 22 January 2002 Chapter 3 20 22 January 2002 Chapter 8 1 22 January 2002
Chapter 1 6 22 January 2002 Chapter 3 21 22 January 2002 Chapter 8 2 22 January 2002
Chapter 1 7 22 January 2002 Chapter 4 1 22 January 2002 Chapter 8 3 22 January 2002
Chapter 1 8 22 January 2002 Chapter 4 2 22 January 2002 Chapter 8 4 22 January 2002
Chapter 2 1 22 January 2002 Chapter 4 3 22 January 2002 Chapter 8 5 22 January 2002
Chapter 2 2 22 January 2002 Chapter 4 4 22 January 2002 Chapter 8 6 22 January 2002
Chapter 2 3 22 January 2002 Chapter 4 5 22 January 2002 Chapter 8 7 22 January 2002
Chapter 2 4 22 January 2002 Chapter 4 6 22 January 2002 Chapter 8 8 22 January 2002
Chapter 2 5 22 January 2002 Chapter 4 7 22 January 2002 Chapter 8 9 22 January 2002
Chapter 2 6 22 January 2002 Chapter 4 8 22 January 2002 Chapter 8 10 22 January 2002
Chapter 2 7 22 January 2002 Chapter 4 9 22 January 2002 Chapter 8 11 22 January 2002
Chapter 2 8 22 January 2002 Chapter 4 10 22 January 2002 Chapter 8 12 22 January 2002
Chapter 2 9 22 January 2002 Chapter 4 11 22 January 2002 Chapter 8 13 22 January 2002
Chapter 2 10 22 January 2002 Chapter 4 12 22 January 2002 Chapter 9 1 22 January 2002
Chapter 2 11 22 January 2002 Chapter 4 13 22 January 2002 Chapter 9 2 22 January 2002
Chapter 2 12 22 January 2002 Chapter 4 14 22 January 2002 Chapter 9 3 22 January 2002
Chapter 2 13 22 January 2002 Chapter 4 15 22 January 2002 Chapter 9 4 22 January 2002
Chapter 2 14 22 January 2002 Chapter 4 16 22 January 2002 Appendix A 1 22 January 2002
Chapter 2 15 22 January 2002 Chapter 4 17 22 January 2002 Appendix A 2 22 January 2002
Chapter 2 16 22 January 2002 Chapter 4 18 22 January 2002 Appendix A 3 22 January 2002
Chapter 2 17 22 January 2002 Chapter 4 19 22 January 2002 Appendix A 4 22 January 2002
Chapter 2 18 22 January 2002 Chapter 5 1 22 January 2002 Appendix A 5 22 January 2002
Chapter 2 19 22 January 2002 Chapter 5 2 22 January 2002
Chapter 2 20 22 January 2002 Chapter 5 3 22 January 2002
Chapter 2 21 22 January 2002 Chapter 5 4 22 January 2002
Chapter 3 1 22 January 2002 Chapter 5 5 22 January 2002
Chapter 3 2 22 January 2002 Chapter 5 6 22 January 2002
Chapter 3 3 22 January 2002 Chapter 5 7 22 January 2002
Chapter 3 4 22 January 2002 Chapter 5 8 22 January 2002
Chapter 3 5 22 January 2002 Chapter 6 1 22 January 2002

22 January 2002 Page iii

CAP 715 An Introduction to Aircraft Maintenance Engineering Human Factors for JAR 66


List of Effective Pages iii

Contents iv

Explanatory Note vi

Amendment Record vii

Foreword viii

Acknowledgements x

Glossary of Terms xi

Chapter 1 Introduction

The Need To Take Human Factors Into Account 1

Incidents and Accidents Attributable To Human Factors / Human Error 4
Murphy’s Law 8

Chapter 2 Human Performance and Limitations

Human Performance as Part of the Maintenance Engineering System 1

Vision 2
Hearing 8
Information Processing 12
Claustrophobia, Physical Access and Fear of Heights 20

Chapter 3 Social Psychology

The Social Environment 1

Responsibility: Individual and Group 2
Motivation and De-motivation 4
Peer Pressure 8
Culture Issues 9
Team Working 12
Management, Supervision and Leadership 14
Maintenance Resource Management (MRM) 18

Chapter 4 Factors Affecting Performance

Fitness and Health 1

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CAP 715 An Introduction to Aircraft Maintenance Engineering Human Factors for JAR 66

Stress: Domestic and Work Related 3

Time Pressure and Deadlines 6
Workload - Overload and Underload 8
Sleep, Fatigue and Shift Work 11
Alcohol, Medication and Drug Abuse 16

Chapter 5 Physical Environment

Noise 1
Fumes 2
Illumination 3
Climate and Temperature 5
Motion and Vibration 6
Confined Spaces 7
Working Environment 7

Chapter 6 Tasks

Physical Work 2
Repetitive Tasks 4
Visual Inspection 5
Complex Systems 7

Chapter 7 Communication

Within and Between Teams 1

Work Logging and Recording 4
Keeping Up-to-Date, Currency 6
Dissemination of Information 6

Chapter 8 Human Error

Error Models and Theories 2

Types of Error in Maintenance Tasks 7
Implications of Errors (i.e. Accidents) 10
Avoiding and Managing Errors 12

Chapter 9 Hazards In The Workplace

Recognising and Avoiding Hazards 1

Appendix A 1

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CAP 715 An Introduction to Aircraft Maintenance Engineering Human Factors for JAR 66

Explanatory Note

1 Introduction

This document is intended to provide an introduction to human factors and human

performance and limitations for ab-initio engineers studying for their JAR-66
engineering licenses. The document expands upon the syllabus items listed in
Module 9 of JAR-66, but is not a fully comprehensive reference document on human
factors in aircraft maintenance.
A separate document, CAP 7161, addresses human factors in maintenance from an
organisational perspective, within a JAR-145 organisation.

1. Civil Aviation Authority (2002) CAP 716 Aviation Maintenance Human Factors (JAA JAR145)

22 January 2002 Page vi

CAP 715 An Introduction to Aircraft Maintenance Engineering Human Factors for JAR 66

Amendment Record

Amendment Date Incorporated by Incorporated on

Edition 1 22 January 2002

22 January 2002 Page vii

CAP 715 An Introduction to Aircraft Maintenance Engineering Human Factors for JAR 66


1.1 An understanding of the importance of human factors to aircraft maintenance

engineering is essential to anyone considering a career as a licensed aircraft engineer.
Human factors impinges on everything an engineer does in the course of their job in
one way or another, from communicating effectively with colleagues to ensuring they
have adequate lighting to carry out their tasks. Knowledge of this subject has a
significant impact on the safety standards expected of the aircraft maintenance
1.2 This document is intended to provide guidance and supporting information in respect
of those subjects contained in the human factors syllabus: module 9 in JAR 66 and
module 13 in BCAR Section L. In this respect, the order in which subjects are
introduced maps on to that in the JAR and BCAR syllabi to enable ready identification
of the associated information. This text primarily concerns itself with the individual
and his responsibilities. A few other topics, not specifically listed in the syllabus, are
also included in order to provide an introduction to the concepts, e.g. Maintenance
Resource Management (MRM), organisational culture issues, etc. It is hoped that in
studying this publication, prospective aircraft engineers will see that human factors is
not just a subject to be passed in an exam, but rather an area that influences how well
they do their job, in terms of both safety and quality, and ultimately the airworthiness
of the aircraft they maintain.
1.3 There are many publications in existence dealing with aviation human factors, but the
majority of these were developed for pilots rather than maintenance personnel.
Whilst much of the material in these publications is relevant, in as far as it describes
human performance and limitations, the contexts and examples used tend to be less
relevant to the maintenance engineer. This publication has been developed
specifically for the maintenance engineer and focuses on research from a number of
sources and incidents investigated by the CAA.
1.4 How to use this Document
This document should be used as a broad starting point for studying human factors
as it affects aircraft maintenance engineering. Some further reading will be needed
for more detailed information concerning human performance and limitations.
Suggested further reading is included throughout the document.
1.5 In order to aid the reader, key terms are highlighted thus.
Definitions and explanations are indicated like this:

Definition: ............

Important points to remember are shown thus:

Remember: ............

Examples to illustrate points are presented thus:

Example: ............

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CAP 715 An Introduction to Aircraft Maintenance Engineering Human Factors for JAR 66

1.6 Whilst this text has been prepared for those personnel wishing to qualify as certifying
staff under JAR66, it is also relevant to all staff working in aircraft maintentance
engineering. Thus whilst the term ‘engineer’ has been used throughout the
document, it is generally used in a generic sense to include all aircraft maintenance
technicians, fitters, licensed engineers, inspectors and supervisors. (In some cases,
it also includes managers, planners, etc.). Where specific reference is made to
Licensed Aircraft Engineers (LAEs), this is made clear in the text.
1.7 Also, for all the female engineers reading this text, please forgive the use of the
masculine gender throughout this document. ‘He’ should be interpreted as ‘he/she’,
and is used merely for ease of reading.

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CAP 715 An Introduction to Aircraft Maintenance Engineering Human Factors for JAR 66


1.1 Many sources of information have been used in the course of producing this
document, including text books on human factors, ergonomics, occupational
psychology and the like (reference to which can be found in footnotes and ‘Further
Reading’ in this document), accident and investigation data, such as reports produced
by the Air Accidents Investigation Branch (AAIB) (see AAIB web site
www.aaib.dtlr.gov.uk) and information from the CAA’s Mandatory Occurrence
Reporting Scheme (MORS) (see CAA web site www.srg.caa.co.uk) and the ICAO
Human Factors Digests. This document has also drawn on the FAA Human Factors
Guide for Aviation Maintenance and various other material from the large body of FAA
funded research into human factors and maintenance engineering. These sources
can be accessed via the Internet on http://hfskyway.faa.gov
1.2 Acknowledgements are given to all those authors, researchers, editors and
participating organisations who contributed to the sources of information used in the
preparation of this document.

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CAP 715 An Introduction to Aircraft Maintenance Engineering Human Factors for JAR 66

Glossary of Terms

AAIB Air Accidents Investigation Branch

ANO Air Navigation Order

APU Auxiliary Power Unit

ATC Air Traffic Control

AWN Airworthiness Notice

BCAR British Civil Airworthiness Requirements

CAA Civil Aviation Authority

CAP Civil Aviation Publication

cd candela

CHIRP Confidential Human Factors Incident Reporting Programme

CRM Crew Resource Management

dB decibels

FAA Federal Aviation Administration

fL footLambert

FOD Foreign Object Damage

FODCOM Flight Operations Department Communication

HFAMI Human Factors in Aviation Maintenance and Inspection

HFCAG Human Factors Combined Action Group

HFRG Human Factors in Reliability Group

HSE Health and Safety Executive

Hz Hertz

IATA International Air Transport Association

ICAO International Civil Aviation Organisation

IMIS Integrated Maintenance Information System

JAR Joint Aviation Requirement

LAE Licensed Aircraft Engineer

lm lumen

lux lumens/m²

MEDA Maintenance Engineering Decision Aid

MM Maintenance Manual

MORS Mandatory Occurrence Report Scheme

MRM Maintenance Resource Management

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CAP 715 An Introduction to Aircraft Maintenance Engineering Human Factors for JAR 66

NIHL Noise Induced Hearing Loss

NDI Non-Destructive Inspection

NDT Non-Destructive Testing

NTSB National Transportation Safety Board

OJT On-the-job Training

REM Rapid Eye Movement

SHEL Model Software, Hardware, Environment, Liveware

SMM Shift Maintenance Manager

SMS Safety Management System

TWA Time Weighted Average

VWF Vibratory - Induced White Finger

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CAP 715 An Introduction to Aircraft Maintenance Engineering Human Factors for JAR 66

Chapter 1 Introduction

This chapter introduces human factors and explains its importance to the aviation
industry. It examines the relationship between human factors and incidents largely in
terms of human error and “Murphy’s Law” (i.e. if it can happen, one day it will).

1 The Need To Take Human Factors Into Account

1.1 In the early days of powered flight, the design, construction and control of aircraft
predominated. The main attributes of the first pilots were courage and the mastery of
a whole new set of skills in the struggle to control the new flying machines.
1.2 As the technical aspects of flight were overcome bit by bit, the role of the people
associated with aircraft began to come to the fore. Pilots were supported initially with
mechanisms to help them stabilise the aircraft, and later with automated systems to
assist the crew with tasks such as navigation and communication. With such
interventions to complement the abilities of pilots, aviation human factors was born.
1.3 As stated in the Foreword, an understanding of the importance of human factors to
aircraft maintenance engineering is essential to anyone considering a career as a
licensed aircraft engineer. This is because human factors will impinge on everything
they do in the course of their job in one way or another.
1.4 What is “Human Factors”?
1.4.1 The term “human factors” is used in many different ways in the aviation industry.
The term is, perhaps, best known in the context of aircraft cockpit design and Crew
Resource Management (CRM). However, those activities constitute only a small
percentage of aviation-related human factors, as broadly speaking it concerns any
consideration of human involvement in aviation.
1.4.2 The use of the term “human factors” in the context of aviation maintenance
engineering is relatively new. Aircraft accidents such as that to the Aloha aircraft in
the USA in 19881 and the BAC 1-11 windscreen accident in the UK in June 19902
brought the need to address human factors issues in this environment into sharp
focus. This does not imply that human factors issues were not present before these
dates nor that human error did not contribute to other incidents; merely that it took an
accident to draw attention to human factors problems and potential solutions.

1. NTSB (1989) Aircraft Accident Report - Aloha Airlines, Flight 243, Boeing 737-200, N73711, near Maui, Hawaii, April 28,
1988. NTSB/AAR-89/03.
2. AAIB (1992) Report on the accident to BAC 1-11, G-BJRT over Didcot, Oxfordshire on 10 June 1990. Aircraft Accident
Report 1/92.

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CAP 715 An Introduction to Aircraft Maintenance Engineering Human Factors for JAR 66

1.4.3 Before discussing how these accidents were related to human factors, a definition of
human factors is required. There are many definitions available. Some authors refer
to the subject as ‘human factors’ and some as ‘ergonomics’. Some see “human
factors” as a scientific discipline and others regard it as a more general part of the
human contribution to system safety. Although there are simple definitions of human
factors such as: “Fitting the man to the job and the job to the man”, a good definition
in the context of aviation maintenance would be:

"Human factors" refers to the study of human capabilities and limitations in the workplace.
Human factors researchers study system performance. That is, they study the interaction
of maintenance personnel, the equipment they use, the written and verbal procedures and
rules they follow, and the environmental conditions of any system. The aim of human
factors is to optimise the relationship between maintenance personnel and systems with a
view to improving safety, efficiency and well-being”.

1.4.4 Thus, human factors include such attributes as:

• human physiology;
• psychology (including perception, cognition, memory, social interaction, error,
• work place design;
• environmental conditions;
• human-machine interface;
• anthropometrics (the scientific study of measurements of the human body).
1.5 The SHEL Model
1.5.1 It can be helpful to use a model to aid in the understanding of human factors, or as a
framework around which human factors issues can be structured. A model which is
often used is the SHEL model, a name derived from the initial letters of its
• Software (e.g. maintenance procedures, maintenance manuals, checklist layout,
• Hardware (e.g. tools, test equipment, the physical structure of aircraft, design of
flight decks, positioning and operating sense of controls and instruments, etc.);
• Environment (e.g. physical environment such as conditions in the hangar,
conditions on the line, etc. and work environment such as work patterns,
management structures, public perception of the industry, etc.);
• Liveware (i.e. the person or people at the centre of the model, including
maintenance engineers, supervisors, planners, managers, etc.).

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CAP 715 An Introduction to Aircraft Maintenance Engineering Human Factors for JAR 66

Figure 1 SHEL Model. Source: Edwards, 1972 (as referenced in ICAO Human
Factors Digest No 1, Circular 216 (1989))

1.5.2 Human factors concentrates on the interfaces between the human (the ‘L’ in the
centre box) and the other elements of the SHEL model1 (see Figure 1), and - from a
safety viewpoint - where these elements can be deficient, e.g.:

S: misinterpretation of procedures, badly written manuals, poorly designed checklists,

untested or difficult to use computer software

H: not enough tools, inappropriate equipment, poor aircraft design for maintainability

E: uncomfortable workplace, inadequate hangar space, extreme temperatures, excessive

noise, poor lighting

L: relationships with other people, shortage of manpower, lack of supervision, lack of

support from managers

1.5.3 As will be covered in this document, man - the “Liveware” - can perform a wide range
of activities. Despite the fact that modern aircraft are now designed to embody the
latest self-test and diagnostic routines that modern computing power can provide,
one aspect of aviation maintenance has not changed: maintenance tasks are still
being done by human beings. However, man has limitations. Since Liveware is at the
centre of the model, all other aspects (Software, Hardware and Environment) must
be designed or adapted to assist his performance and respect his limitations. If
these two aspects are ignored, the human - in this case the maintenance engineer -
will not perform to the best of his abilities, may make errors, and may jeopardise
1.5.4 Thanks to modern design and manufacturing, aircraft are becoming more and more
reliable. However, it is not possible to re-design the human being: we have to accept
the fact that the human being is intrinsically unreliable. However, we can work around
that unreliability by providing good training, procedures, tools, duplicate inspections,
etc. We can also reduce the potential for error by improving aircraft design such that,
for example, it is physically impossible to reconnect something the wrong way

1. Hawkins, F.H. (1993) Human Factors in Flight. Aldershot: Ashgate

2. Dohertey, S. (1999) Development of a Human Hazard Analysis Method for Crossed Connection Incidents in Aircraft
Maintenance. MSc Thesis. Bournemouth University.

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CAP 715 An Introduction to Aircraft Maintenance Engineering Human Factors for JAR 66

One of the main aims of this document is to help all personnel in the engineering
maintenance environment (technicians, engineers, planners, managers, etc.) to recognise
human performance limitations in themselves and others, and to be able to avoid, detect
and rectify errors or error prone behaviour and practices

Further Reading:
a) Human Factors Digest No. 1. Fundamental Human Factors Concepts. (ICAO
Circular 216)
b) Human Factors Digest No. 12: Human Factors in Aircraft Maintenance and
Inspection. 1995. (ICAO Circular 253)

2 Incidents and Accidents Attributable To Human Factors / Human Error

2.1 In 1940, it was calculated that approximately 70% of all aircraft accidents were
attributable to man’s performance, that is to say human error1. When the
International Air Transport Association (IATA) reviewed the situation 35 years later,
they found that there had been no reduction in the human error component of
accident statistics2 (Figure 2).



Flight Crew, ATC,

Maintenance, Aircraft
Design, etc.

Figure 2 The dominant role played by human performance in civil aircraft accidents
Source: IATA, 1975

2.2 A study was carried out in 1986, in the USA by Sears3, looking at significant accident
causes in 93 aircraft accidents. These were as follows:
Causes/ major contributory factors % of accidents in
which this was a factor
• Pilot deviated from basic operational procedures 33
• Inadequate cross-check by second crew member 26
• Design faults 13
• Maintenance and inspection deficiencies 12
• Absence of approach guidance 10

1. Meier Muler, H. (1940) Flugwehr und Technik, 1:412-414 and 2:40-42.

2. IATA (1975) Safety in Flight Operations. The 20th Technical Conference of IATA, Istanbul.
3. Sears, R.L. A new look at accident contributions and the implications of operational training programmes (unpublished
report). Quoted in Graeber and Marx: Reducing Human Error in Aviation Maintenance Operations. (presented at the
Flight Safety Foundation 46th Annual International Air Safety Seminar, Kuala Lumpur, Malaysia, 1993).

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CAP 715 An Introduction to Aircraft Maintenance Engineering Human Factors for JAR 66

• Captain ignored crew inputs 10

• Air traffic control failures or errors 9
• Improper crew response during abnormal conditions 9
• Insufficient or incorrect weather information 8
• Runways hazards 7
• Air traffic control/crew communication deficiencies 6
• Improper decision to land 6
2.3 As can be seen from the list, maintenance and inspection deficiencies are one of the
major contributory factors to accidents.
2.4 The UK CAA carried out a similar exercise1 in 1998 looking at causes of 621 global
fatal accidents between 1980 and 1996. Again, the area “maintenance or repair
oversight / error / inadequate” featured as one of the top 10 primary causal factors.
2.5 It is clear from such studies that human factors problems in aircraft maintenance
engineering are a significant issue, warranting serious consideration.
2.6 Examples of Incidents and Accidents
2.6.1 There have been several ‘high profile’ incidents and accidents which have involved
maintenance human factors problems. The Human Factors in Aviation Maintenance
and Inspection (HFAMI) web site2 lists 24 NTSB accident reports where maintenance
human factors problems have been the cause or a major contributory factor. In the
UK, there have been several major incidents and accidents, details of which can be
found on the AAIB web site3. Some of the major incidents and accidents are
summarised below. These are:
• Accident to Boeing 737, (Aloha flight 243), Maui, Hawaii, April 28 1988;
• Accident to BAC One-Eleven, G-BJRT (British Airways flight 5390), over Didcot,
Oxfordshire on 10 June 1990;
• Incident involving Airbus A320, G-KMAM at London Gatwick Airport, on 26 August
• Incident involving Boeing 737, G-OBMM near Daventry, on 23 February 1995.

The accident involving Aloha flight 243 in April 1988 involved 18 feet of the upper cabin
structure suddenly being ripped away in flight due to structural failure. The Boeing 737
involved in this accident had been examined, as required by US regulations, by two of the
engineering inspectors. One inspector had 22 years experience and the other, the chief
inspector, had 33 years experience. Neither found any cracks in their inspection. Post-
accident analysis determined there were over 240 cracks in the skin of this aircraft at the
time of the inspection. The ensuing investigation identified many human-factors-related
problems leading to the failed inspections.

As a result of the Aloha accident, the US instigated a programme of research looking into
the problems associated with human factors and aircraft maintenance, with particular
emphasis upon inspection.

1. CAA (1998) CAP 681: Global Fatal Accident Review; 1980-1996. UK Civil Aviation Authority.
2. http://hfskyway.faa.gov
3. www.aaib.dtlr.gov.uk

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CAP 715 An Introduction to Aircraft Maintenance Engineering Human Factors for JAR 66

On June 10th 1990 in the UK, a BAC1-11 (British Airways flight 5390) was climbing through
17,300 feet on departure from Birmingham International Airport when the left windscreen,
which had been replaced prior to flight, was blown out under the effects of cabin pressure
when it overcame the retention of the securing bolts, 84 of which, out of a total of 90,
were smaller than the specified diameter. The commander was sucked halfway out of the
windscreen aperture and was restrained by cabin crew whilst the co-pilot flew the aircraft
to a safe landing at Southampton Airport.

The Shift Maintenance Manager (SMM), short-handed on a night shift, had decided to carry
out the windscreen replacement himself. He consulted the Maintenance Manual (MM) and
concluded that it was a straightforward job. He decided to replace the old bolts and, taking
one of the bolts with him (a 7D), he looked for replacements. The storeman advised him
that the job required 8Ds, but since there were not enough 8Ds, the SMM decided that
7Ds would do (since these had been in place previously). However, he used sight and
touch to match the bolts and, erroneously, selected 8Cs instead, which were longer but
thinner. He failed to notice that the countersink was lower than it should be, once the bolts
were in position. He completed the job himself and signed it off, the procedures not
requiring a pressure check or duplicated check.

There were several human factors issues contributing to this incident, including perceptual
errors made by the SMM when identifying the replacement bolts, poor lighting in the
stores area, failure to wear spectacles, circadian effects, working practices, and possible
organisational and design factors.

An incident in the UK in August 1993 involved an Airbus 320 which, during its first flight
after a flap change, exhibited an undemanded roll to the right after takeoff. The aircraft
returned to Gatwick and landed safely. The investigation discovered that during
maintenance, in order to replace the right outboard flap, the spoilers had been placed in
maintenance mode and moved using an incomplete procedure; specifically the collars and
flags were not fitted. The purpose of the collars and the way in which the spoilers
functioned was not fully understood by the engineers. This misunderstanding was due, in
part, to familiarity of the engineers with other aircraft (mainly 757) and contributed to a lack
of adequate briefing on the status of the spoilers during the shift handover. The locked
spoiler was not detected during standard pilot functional checks.

In the UK in February 1995, a Boeing 737-400 suffered a loss of oil pressure on both
engines. The aircraft diverted and landed safely at Luton Airport. The investigation
discovered that the aircraft had been subject to borescope inspections on both engines
during the preceding night and the high pressure (HP) rotor drive covers had not been
refitted, resulting in the loss of almost all the oil from both engines during flight. The line
engineer was originally going to carry out the task, but for various reasons he swapped
jobs with the base maintenance controller. The base maintenance controller did not have
the appropriate paperwork with him. The base maintenance controller and a fitter carried
out the task, despite many interruptions, but failed to refit the rotor drive covers. No
ground idle engine runs (which would have revealed the oil leak) were carried out. The job
was signed off as complete.

2.6.2 In all three of these UK incidents, the engineers involved were considered by their
companies to be well qualified, competent and reliable employees. All of the incidents
were characterised by the following:
• There were staff shortages;
• Time pressures existed;
• All the errors occurred at night;

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CAP 715 An Introduction to Aircraft Maintenance Engineering Human Factors for JAR 66

• Shift or task handovers were involved;

• They all involved supervisors doing long hands-on tasks;
• There was an element of a “can-do” attitude;
• Interruptions occurred;
• There was some failure to use approved data or company procedures;
• Manuals were confusing;
• There was inadequate pre-planning, equipment or spares.
Source: AAIB, 19881
2.7 Incidents and Accidents - A Breakdown in Human Factors
2.7.1 In all of the examples above, the accident or incident was preventable and could have
been avoided if any one of a number of things had been done differently. In some
cases, a number of individuals were involved and the outcome could have been
modified if any one of them had reacted or queried a particular action. In each
situation however, the individuals failed to recognise or react to signs of potential
hazards, did not react as expected of them, or allowed themselves to be diverted
from giving their attention to the task in hand, leaving themselves open to the
likelihood of committing an error.
2.7.2 As with many incidents and accidents, all the examples above involved a series of
human factors problems which formed an error chain (see Figure 3). If any one of the
links in this ‘chain’ had been broken by building in measures which may have
prevented a problem at one or more of these stages, these incidents may have been


C rew

M an a gem en t

M aintenance

If we can break just one link of the chain, the accident does not happen

Figure 3 The Error Chain. Source: Boeing2

1. King, D. (1988) Learning Lessons the (not quite so) Hard Way; Incidents - the route to human factors in engineering. In:
12th Symposium on Human Factors in Aviation Maintenance. March 1988.
2. Boeing (1993) Accident Prevention Strategies: Commercial Jet Aircraft Accidents World Wide Operations 1982-1991.

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2.7.3 Further chapters in this document aim to help the aircraft maintenance engineer to
identify where the vulnerable areas might be within the maintenance ‘link’, how to
identify them, and to provide an introduction to those human factors practices and
principles which should prevent the error chain reaching a catastrophic conclusion.
Further Reading:
a) Marx, D.A. and Graeber, C. (1994) Human Error in Aircraft Maintenance; Chapter
5. In: Johnston, N., McDonald, N., Fuller, R. (Eds) (1994) Aviation Psychology in
Practice. Aldershot: Avebury Aviation.
b) Reason, J.T. (1995) The BAC 1-11 windscreen accident, Chapter 4. In: Maurino, D.,
Reason, J.T., Johnston, N., Lee, R. (Eds) (1995) Beyond Aviation Human Factors.
Aldershot: Avebury Aviation.
c) Reason, J.T. (1997) Managing the Risks of Organisational Accidents. Aldershot:
d) Reason, J.T. (1991) Human Error. Cambridge: Cambridge University Press.
e) NTSB. Aircraft Accident Report--Aloha Airlines, Flight 243, Boeing 737-200,
N73711, near Maui, Hawaii, April 28, 1988. NTSB 89/03.
f) AAIB (1992) Report on the accident to BAC 1-11, G-BJRT over Didcot, Oxfordshire
on 10 June 1990. Aircraft Accident Report 1/92.
g) AAIB (1995) Report on the incident to Airbus A320-212, at London Gatwick Airport,
on 26 August 1993. Aircraft Incident Report 2/95.
h) AAIB (1996) Report on the incident to a Boeing 737-400, G-OBMM near Daventry
on 25 February 1995. Aircraft Accident Report 3/96.

3 Murphy’s Law

3.1 There is a tendency among human beings towards complacency. The belief that an
accident will never happen to “me” or to “my Company” can be a major problem
when attempting to convince individuals or organisations of the need to look at
human factors issues, recognise risks and to implement improvements, rather than
merely to pay ‘lip-service’ to human factors.

“Murphy’s Law” can be regarded as the notion: “If something can go wrong, it will.”

3.2 If everyone could be persuaded to acknowledge Murphy’s Law, this might help
overcome the “it will never happen to me” belief that many people hold. It is not
true that accidents only happen to people who are irresponsible or ‘sloppy’. The
incidents and accidents described in paragraph 2. show that errors can be made by
experienced, well-respected individuals and accidents can occur in organisations
previously thought to be “safe”.

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Chapter 2 Human Performance and Limitations

The intention of this chapter is to provide an overview of those key physical and
mental human performance characteristics which are likely to affect an aircraft
maintenance engineer in his working environment, such as his vision, hearing,
information processing, attention and perception, memory, judgement and decision

1 Human Performance as Part of the Maintenance Engineering System

1.1 Just as certain mechanical components used in aircraft maintenance engineering

have limitations, engineers themselves have certain capabilities and limitations that
must be considered when looking at the maintenance engineering ‘system’. For
instance, rivets used to attach aluminium skin to a fuselage can withstand forces that
act to pull them apart. It is clear that that these rivets will eventually fail if enough
force is applied to them. While the precise range of human capabilities and limitations
might not be as well-defined as the performance range of mechanical or electrical
components, the same principles apply in that human performance is likely to
degrade and eventually ‘fail’ under certain conditions (e.g. stress).
1.2 Mechanical components in aircraft can, on occasion, suffer catastrophic failures.
Man, can also fail to function properly in certain situations. Physically, humans
become fatigued, are affected by the cold, can break bones in workplace accidents,
etc. Mentally, humans can make errors, have limited perceptual powers, can exhibit
poor judgement due to lack of skills and knowledge, etc. In addition, unlike
mechanical components, human performance is also affected by social and emotional
factors. Therefore failure by aircraft maintenance engineers can also be to the
detriment of aircraft safety.
1.3 The aircraft engineer is the central part of the aircraft maintenance system. It is
therefore very useful to have an understanding of how various parts of his body and
mental processes function and how performance limitations can influence his
effectiveness at work.

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2 Vision

2.1 The Basic Function of the Eye

In order to understand vision, it is useful first to know a little about the anatomy of the
eye (see Figure 4). The basic structure of the eye is similar to a simple camera with
an aperture (the iris), a lens, and a light sensitive surface (the retina). Light enters the
eye through the cornea, then passes through the iris and the lens and falls on the
retina. Here the light stimulates the light-sensitive cells on the retina (rods and cones)
and these pass small electrical impulses by way of the optic nerve to the visual
cortex in the brain. Here, the electrical impulses are interpreted and an image is

Figure 4 The human eye

2.2 The Cornea

The cornea is a clear ‘window’ at the very front of the eye. The cornea acts as a fixed
focusing device. The focusing is achieved by the shape of the cornea bending the
incoming light rays. The cornea is responsible for between 70% and 80% of the total
focusing ability (refraction) of the eye.
2.3 The Iris and Pupil
The iris (the coloured part of the eye) controls the amount of light that is allowed to
enter the eye. It does this by varying the size of the pupil (the dark area in the centre
of the iris). The size of the pupil can be changed very rapidly to cater for changing light
levels. The amount of light can be adjusted by a factor of 5:1.

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2.4 The Lens

After passing through the pupil, the light passes through the lens. Its shape is
changed by the muscles (cillary muscles) surrounding it which results in the final
focusing adjustment to place a sharp image onto the retina. The change of shape of
the lens is called accommodation. In order to focus clearly on a near object, the lens
is thickened. To focus on a distant point, the lens is flattened. The degree of
accommodation can be affected by factors such as fatigue or the ageing process.

When a person is tired accommodation is reduced, resulting in less sharp vision

(sharpness of vision is known as visual acuity).

2.5 The Retina

2.5.1 The retina is located on the rear wall of the eyeball. It is made up of a complex layer
of nerve cells connected to the optic nerve. Two types of light sensitive cells are
found in the retina - rods and cones. The central area of the retina is known as the
fovea and the receptors in this area are all cones. It is here that the visual image is
typically focused. Moving outwards, the cones become less dense and are
progressively replaced by rods, so that in the periphery of the retina, there are only

Cones function in good light and are capable of detecting fine detail and are colour
sensitive. This means the human eye can distinguish about 1000 different shades of colour.

Rods cannot detect colour. They are poor at distinguishing fine detail, but good at detecting
movement in the edge of the visual field (peripheral vision). They are much more
sensitive at lower light levels. As light decreases, the sensing task is passed from the
cones to the rods. This means in poor light levels we see only in black and white and
shades of grey.

2.5.2 At the point at which the optic nerve joins the back of the eye, a ‘blind spot’ occurs.
This is not evident when viewing things with both eyes (binocular vision), since it is
not possible for the image of an object to fall on the blind spots of both eyes at the
same time. Even when viewing with one eye (monocular vision), the constant rapid
movement of the eye (saccades) means that the image will not fall on the blind spot
all the time. It is only when viewing a stimulus that appears very fleetingly (e.g. a light
flashing), that the blind spot may result in something not being seen. In maintenance
engineering, tasks such as close visual inspection or crack detection should not cause
such problems, as the eye or eyes move across and around the area of interest
(visual scanning).
2.6 Factors Affecting Clarity of Sight
2.6.1 The eye is very sensitive in the right conditions (e.g. clear air, good light, etc.). In fact,
the eye has approximately 1.2 million nerve cells leading from the retinas to the area
of the brain responsible for vision, while there are only about 50,000 from the inner
ears - making the eye about 24 times more sensitive than the ear.
2.6.2 Before considering factors that can influence and limit the performance of the eye, it
is necessary to describe visual acuity.

Visual acuity is the ability of the eye to discriminate sharp detail at varying distances.

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2.6.3 An individual with an acuity of 20/20 vision should be able to see at 20 feet that which
the so-called ‘normal’ person is capable of seeing at this range. It may be expressed
in metres as 6/6 vision. The figures 20/40 mean that the observer can read at 20 feet
what a ‘normal’ person can read at 40 feet.
2.6.4 Various factors can affect and limit the visual acuity of the eye. These include:
• Physical factors such as:
• physical imperfections in one or both eyes (short sightedness, long
• age.
• The influence of ingested foreign substances such as:
• drugs,
• medication,
• alcohol,
• cigarettes.
• Environmental factors such as:
• amount of light available,
• clarity of the air (e.g. dust, mist, rain, etc.).
• Factors associated with object being viewed such as:
• size and contours of the object,
• contrast of the object with its surroundings,
• relative motion of the object,
• distance of the object from the viewer,
• the angle of the object from the viewer.
2.6.5 Each of these factors will now be examined in some detail.
2.7 Physical Factors
2.7.1 Long sight - known as Hypermetropia - is caused by a shorter than normal eyeball
which means that the image is formed behind the retina (Figure 5). If the cornea and
the lens cannot use their combined focusing ability to compensate for this, blurred
vision will result when looking at close objects.

Figure 5 A convex lens will overcome long sightedness by bending light inwards
before it reaches the cornea.

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2.7.2 Short sight - known as Myopia - is where the eyeball is longer than normal, causing
the image to be formed in front of the retina (Figure 6). If the accommodation of the
lens cannot counteract this then distant objects are blurred.

Figure 6 A concave lens will overcome short sightedness by bending light

outwards before it reaches the cornea.

2.7.3 Other visual problems include:

• cataracts - clouding of the lens usually associated with ageing;
• astigmatism - a misshapen cornea causing objects to appear irregularly shaped;
• glaucoma - a build up in pressure of the fluid within the eye which can cause
damage to the optic nerve and even blindness;
• migraine - severe headaches that can cause visual disturbances.
2.7.4 Finally as a person grows older, the lens becomes less flexible meaning that it is
unable to accommodate sufficiently. This is known as presbyopia and is a form of
long sightedness. Consequently, after the age of 40, spectacles may be required for
near vision, especially in poor light conditions. Fatigue can also temporarily affect
accommodation, causing blurred vision for close work.
2.8 Foreign Substances
Vision can be adversely affected by the use of certain drugs and medications, alcohol,
and smoking cigarettes. With smoking, carbon monoxide which builds up in the
bloodstream allows less oxygen to be carried in the blood to the eyes. This is known
as hypoxia and can impair rapidly the sensitivity of the rods. Alcohol can have similar
effects, even hours after the last drink.
2.9 Environmental Factors
2.9.1 Vision can be improved by increasing the lighting level, but only up to a point, as the
law of diminishing returns operates. Also, increased illumination could result in
increased glare. Older people are more affected by the glare of reflected light than
younger people. Moving from an extremely bright environment to a dimmer one has
the effect of vision being severely reduced until the eyes get used to less light being
available. This is because the eyes have become light adapted. If an engineer works
in a very dark environment for a long time, his eyes gradually become dark adapted
allowing better visual acuity. This can take about 7 minutes for the cones and 30
minutes for the rods. As a consequence, moving between a bright hanger (or the
inside of an aircraft) to a dark apron area at night can mean that the maintenance
engineer must wait for his eyes to adjust (adapt). In low light conditions, it is easier to
focus if you look slightly to one side of an object. This allows the image to fall outside
the fovea and onto the part of the retina which has many rods.

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2.9.2 Any airborne particles such as dust, rain or mist can interfere with the transmission
of light through the air, distorting what is seen. This can be even worse when
spectacles are worn, as they are susceptible to getting dirty, wet, misted up or
scratched. Engineers who wear contact lenses (especially hard or gas-permeable
types) should take into account the advice from their optician associated with the
maximum wear time - usually 8 to 12 hours - and consider the effects which extended
wear may have on the eyes, such as drying out and irritation. This is particularly
important if they are working in an environment which is excessively dry or dusty, as
airborne particles may also affect contact lens wear. Goggles should be worn where
2.10 The Nature of the Object Being Viewed
Many factors associated with the object being viewed can also influence vision. We
use information from the objects we are looking at to help distinguish what we are
seeing. These are known as visual cues. Visual cues often refer to the comparison
of objects of known size to unknown objects. An example of this is that we associate
small objects with being further away. Similarly, if an object does not stand out well
from its background (i.e. it has poor contrast with its surroundings), it is harder to
distinguish its edges and hence its shape. Movement and relative motion of an object,
as well as distance and angle of the object from the viewer, can all increase visual
2.11 Colour Vision
2.11.1 Although not directly affecting visual acuity, inability to see particular colours can be
a problem for the aircraft maintenance engineer. Amongst other things, good colour
vision for maintenance engineers is important for:
• Recognising components;
• Distinguishing between wires;
• Using various diagnostic tools;
• Recognising various lights on the airfield (e.g. warning lights).
2.11.2 Colour defective vision is usually hereditary, although may also occur as a temporary
condition after a serious illness.

Colour-defective vision (normally referred to incorrectly as colour blindness) affects about

8% of men but only 0.5% of women. The most common type is difficulty in distinguishing
between red and green. More rarely, it is possible to confuse blues and yellows.

2.11.3 There are degrees of colour defective vision, some people suffering more than
others. Individuals may be able to distinguish between red and green in a well-lit
situation but not in low light conditions. Colour defective people typically see the
colours they have problems with as shades of neutral grey.
2.11.4 Ageing also causes changes in colour vision. This is a result of progressive yellowing
of the lens, resulting in a reduction in colour discrimination in the blue-yellow range.
Colour defective vision and its implications can be a complex area and care should be
taken not to stop an engineer from performing certain tasks merely because he
suffers from some degree of colour deficient vision. It may be that the type and
degree of colour deficiency is not relevant in their particular job. However, if
absolutely accurate colour discrimination is critical for a job, it is important that
appropriate testing and screening be put in place.

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2.12 Vision and the Aircraft Maintenance Engineer

2.12.1 It is important for an engineer, particularly one who is involved in inspection tasks, to
have adequate vision to meet the task requirements. As discussed previously, age
and problems developing in the eye itself can gradually affect vision. Without regular
vision testing, aircraft maintenance engineers may not notice that their vision is
2.12.2 In the UK, the CAA have produced guidance1 which states:
“A reasonable standard of eyesight is needed for any aircraft engineer to
perform his duties to an acceptable degree. Many maintenance tasks
require a combination of both distance and near vision. In particular, such
consideration must be made where there is a need for the close visual
inspection of structures or work related to small or miniature
components. The use of glasses or contact lenses to correct any vision
problems is perfectly acceptable and indeed they must be worn as
prescribed. Frequent checks should be made to ensure the continued
adequacy of any glasses or contact lenses. In addition, colour
discrimination may be necessary for an individual to drive in areas where
aircraft manoeuvre or where colour coding is used, e.g. in aircraft wiring.
Organisations should identify any specific eyesight requirement and put
in place suitable procedures to address these issues.”
2.12.3 Often, airline companies or airports will set the eyesight standards for reasons other
than aircraft maintenance safety, e.g. for insurance purposes, or for driving on the
2.12.4 Ultimately, what is important is for the individual to recognise when his vision is
adversely affected, either temporarily or permanently, and to consider carefully the
possible consequences should they continue to work if the task requires good vision.
Further Reading:
a) Campbell, R.D. and Bagshaw, M. (1999) Human Performance and Limitations in
Aviation (2nd edition). Oxford: Blackwell Scientific, Section 3.2.
b) Hawkins, F.H. (1993) Human Factors in Flight (2nd edition). Aldershot: Ashgate -
Chapter 5.
c) Thom, T. (1999) The Air Pilot’s Manual Volume 6: Human Factors and Pilot
Performance (3rd edition). Shrewsbury: Airlife Publishing - Chapter 2.
d) Green, R.G., Muir, H., James, M., Gradwell, D. and Green, R.L. (1996) Human
Factors for Pilots (2nd edition). Aldershot: Ashgate - Sections 1a9 and 1b2.

1. CAA (1999) CAP455: Airworthiness Notices. AWN47. UK Civil Aviation Authority, paragraph 3.4.

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3 Hearing

3.1 The Basic Function of the Ear

3.1.1 The ear performs two quite different functions. It is used to detect sounds by
receiving vibrations in the air, and secondly, it is responsible for balance and sensing
acceleration. Of these two, the hearing aspect is more pertinent to the maintenance
engineer, and thus it is necessary to have a basic appreciation of how the ear works.
3.1.2 As can be seen in Figure 7, the ear has three divisions: outer ear, middle ear and
inner ear. These act to receive vibrations from the air and turn these signals into
nerve impulses that the brain can recognise as sounds.


Outer ear

Eustachian Tube

Figure 7 The human ear

3.2 Outer Ear

The outer part of the ear directs sounds down the auditory canal, and on to the
eardrum. The sound waves will cause the eardrum to vibrate.
3.3 Middle Ear
Beyond the eardrum is the middle ear which transmits vibrations from the eardrum
by way of three small bones known as the ossicles, to the fluid of the inner ear. The
middle ear also contains two muscles which help to protect the ear from sounds
above 80 dB by means of the acoustic or aural reflex, reducing the noise level by up
to 20 dB. However, this protection can only be provided for a maximum of about 15
minutes, and does not provide protection against sudden impulse noise such as
gunfire. It does explain why a person is temporarily ‘deafened’ for a few seconds after
a sudden loud noise. The middle ear is usually filled with air which is refreshed by way
of the eustachian tube which connects this part of the ear with the back of the nose
and mouth. However, this tube can allow mucus to travel to the middle ear which can
build up, interfering with normal hearing.

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3.4 Inner Ear

Unlike the middle ear, the inner ear is filled with fluid. The last of the ossicles in the
middle ear is connected to the cochlea. This contains a fine membrane (the basilar
membrane) covered in hair-like cells which are sensitive to movement in the fluid.
Any vibrations they detect cause neural impulses to be transmitted to the brain via
the auditory nerve.

The amount of vibration detected in the cochlea depends on the volume and pitch of the
original sound.

3.5 Performance and Limitations of the Ear

3.5.1 The performance of the ear is associated with the range of sounds that can be heard
- both in terms of the pitch (frequency) and the volume of the sound.

The audible frequency range that a young person can hear is typically between 20 and
20,000 cycles per second (or Hertz), with greatest sensitivity at about 3000 Hz.

3.5.2 Volume (or intensity) of sound is measured in decibels (dB). Table 1 shows intensity
levels for various sounds and activities.

Table 1 Typical sound levels for various activities

Approximate Intensity level


Rustling of leaves / Whisper 20

Conversation at 2m 50

Typewriter at 1m 65

Car at 15m 70

Lorry at 15m 75

Power Mower at 2m 90

Propellor aircraft at 300m 100

Jet aircraft at 300m 110

Standing near a propellor aircraft 120

Threshold of pain 140

Immediate hearing damage results 150

3.6 Impact of Noise on Performance

3.6.1 Noise can have various negative effects in the workplace. It can:
• be annoying (e.g. sudden sounds, constant loud sound, etc.);
• interfere with verbal communication between individuals in the workplace;
• cause accidents by masking warning signals or messages;
• be fatiguing and affect concentration, decision making, etc.;
• damage workers’ hearing (either temporarily or permanently).

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3.6.2 Intermittent and sudden noise are generally considered to be more disruptive than
continuous noise at the same level. In addition, high frequency noise generally has a
more adverse affect on performance than lower frequency. Noise tends to increase
errors and variability, rather than directly affect work rate. This subject is discussed
further in Chapter 5.
3.7 Hearing Impairment
3.7.1 Hearing loss can result from exposure to even relatively short duration noise. The
degree of impairment is influenced mainly by the intensity of the noise. Such damage
is known as Noise Induced Hearing Loss (NIHL). The hearing loss can be temporary
- lasting from a few seconds to a few days - or permanent. Temporary hearing loss
may be caused by relatively short exposure to very loud sound, as the hair-like cells
on the basilar membrane take time to ‘recover’. With additional exposure, the amount
or recovery gradually decreases and hearing loss becomes permanent. Thus, regular
exposure to high levels of noise over a long period may permanently damage the hair-
like cells in the cochlea, leading to irreversible hearing impairment.
3.7.2 The UK ‘Noise at Work’ regulations1 (1989) impose requirements upon employers.
They stipulate three levels of noise at which an employer must act:
a) 85 decibels (if normal speech cannot be heard clearly at 2 metres), employer must;
• assess the risk to employees’ hearing,
• tell the employees about the risks and what precautions are proposed,
• provide their employees with personal ear protectors and explain their use.
b) 90 decibels (if normal speech cannot be heard clearly at 1 metre) employer must;
• do all that is possible to reduce exposure to the noise by means other than
by providing hearing protection,
• mark zones where noise reaches the second level and provide recognised
signs to restrict entry.
c) 140 decibels (noise causes pain).
3.7.3 The combination of duration and intensity of noise can be described as noise dose.
Exposure to any sound over 80 dB constitutes a noise dose, and can be measured
over the day as an 8 hour Time Weighted Average sound level (TWA).

For example, a person subjected to 95 decibels for 3.5 hours, then 105 decibels for 0.5
hours, then 85 decibels for 4 hours, results in a TWA of 93.5 which exceeds the
recommended maximum TWA of 90 decibels.

3.7.4 Permanent hearing loss may occur if the TWA is above the recommended maximum.

It is normally accepted that a TWA noise level exceeding 85 dB for 8 hours is hazardous
and potentially damaging to the inner ear. Exposure to noise in excess of 115 decibels
without ear protection, even for a short duration, is not recommended.

1. Stranks, J. (2000) Handbook of Health and Safety Practice (5th edition). Pearson Education Ltd.

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3.8 Hearing Protection

3.8.1 Hearing protection is available, to a certain extent, by using ear plugs or ear

Noise levels can be reduced (attenuated) by up to 20 decibels using ear plugs and 40
decibels using ear muffs. However, using ear protection will tend to adversely interfere
with verbal communication. Despite this, it must be used consistently and as instructed to
be effective.

3.8.2 It is good practice to reduce noise levels at source, or move noise away from workers.
Often this is not a practical option in the aviation maintenance environment. Hearing
protection should always be used for noise, of any duration, above 115 dB. Referring
again to Table 1, this means that the aviation maintenance engineer will almost
always need to use some form of hearing protection when in reasonably close
proximity (about 200 - 300m) to aircraft whose engines are running.
3.9 Presbycusis
Hearing deteriorates naturally as one grows older. This is known as presbycusis. This
affects ability to hear high pitch sounds first, and may occur gradually from the 30’s
onwards. When this natural decline is exacerbated by Noise Induced Hearing Loss, it
can obviously occur rather sooner.
3.10 Hearing and the Aircraft Maintenance Engineer
3.10.1 The UK CAA1 makes the following recommendations regarding hearing:
“The ability to hear an average conversational voice in a quiet room at a
distance of 2 metres (6 feet) from the examiner is recommended as a
routine test. Failure of this test would require an audiogram to be carried
out to provide an objective assessment. If necessary, a hearing aid may
be worn but consideration should be given to the practicalities of wearing
the aid during routine tasks demanded of the individual.”
3.10.2 It is very important that the aircraft maintenance engineer understands the limited
ability of the ears to protect themselves from damage due to excessive noise. Even
though engineers should be given appropriate hearing protection and trained in its
use, it is up to individuals to ensure that they actually put this to good use. It is a
misconception that the ears get used to constant noise: if this noise is too loud, it will
damage the ears gradually and insidiously. Noise in the workplace is discussed further
in Chapter 5.
Further Reading:
a) Campbell, R.D. and Bagshaw, M. (1999) Human Performance and Limitations in
Aviation (2nd edition). Oxford: Blackwell Scientific, Section 3.3.
b) Thom, T. (1999) The Air Pilot’s Manual Volume 6: Human Factors and Pilot
Performance (3rd edition). Shrewsbury: Airlife Publishing - Chapter 3.
c) Green, R.G., Muir, H., James, M., Gradwell, D. and Green, R.L. (1996) Human
Factors for Pilots (2nd edition). Aldershot: Ashgate - Sections 1a8 and 1b1.

1. CAA (1999) CAP455: Airworthiness Notices. AWN47. UK Civil Aviation Authority - paragraph 3.5.

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4 Information Processing

The previous sections have described the basic functions and limitations of two of the
senses used by aircraft maintenance engineers in the course of their work. This
section examines the way the information gathered by the senses is processed by
the brain. The limitations of the human information processing system are also

Information processing is the process of receiving information through the senses,

analysing it and making it meaningful.

4.1 An Information Processing Model

Information processing can be represented as a model. This captures the main
elements of the process, from receipt of information via the senses, to outputs such
as decision making and actions. One such model is shown in Figure 8.

Sensory Stores



Short Term DECISION Long Term
Memory Memory



Figure 8 A functional model of human information processing

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4.2 Sensory Receptors and Sensory Stores

Physical stimuli are received via the sensory receptors (eyes, ears, etc.) and stored
for a very brief period of time in sensory stores (sensory memory). Visual information
is stored for up to half a second in iconic memory and sounds are stored for slightly
longer (up to 2 seconds) in echoic memory. This enables us to remember a sentence
as a sentence, rather than merely as an unconnected string of isolated words, or a
film as a film, rather than as a series of disjointed images.
4.3 Attention and Perception
4.3.1 Having detected information, our mental resources are concentrated on specific
elements - this is attention.

Attention can be thought of as the concentration of mental effort on sensory or mental


Source: Solso, 19951

4.3.2 Although attention can move very quickly from one item to another, it can only deal
with one item at a time. Attention can take the form of:
• selective attention,
• divided attention,
• focused attention
• sustained attention.
4.3.3 Selective attention occurs when a person is monitoring several sources of input,
with greater attention being given to one or more sources which appear more
important. A person can be consciously attending to one source whilst still sampling
other sources in the background. Psychologists refer to this as the ‘cocktail party
effect’ whereby you can be engrossed in a conversation with one person but your
attention is temporarily diverted if you overhear your name being mentioned at the
other side of the room, even though you were not aware of listening in to other
people’s conversations. Distraction is the negative side of selective attention.
4.3.4 Divided attention is common in most work situations, where people are required to
do more than one thing at the same time. Usually, one task suffers at the expense of
the other, more so if they are similar in nature. This type of situation is also sometimes
referred to as time sharing.
4.3.5 Focused attention is merely the skill of focussing one’s attention upon a single
source and avoiding distraction.
4.3.6 Sustained attention as its name implies, refers to the ability to maintain attention
and remain alert over long periods of time, often on one task. Most of the research
has been carried out in connection with monitoring radar displays, but there is also
associated research which has concentrated upon inspection tasks.2
4.3.7 Attention is influenced by arousal level and stress. This can improve attention or
damage it depending on the circumstances. This is covered in more detail in Chapter
4, Sections 2, 3 and 4.

1. Solso, R.L. (1995) Cognitive Psychology (4th edition.). Boston: Allyn and Bacon.
2. Search for “Inspection” on the Human Factors in Aviation Maintenance and Inspection (HFAMI) website http://

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4.3.8 Perception involves the organisation and interpretation of sensory data in order to
make it meaningful, discarding non-relevant data, i.e. transforming data into
information. Perception is a highly sophisticated mechanism and requires existing
knowledge and experience to know what data to keep and what to discard, and how
to associate the data in a meaningful manner.

Perception can be defined as the process of assembling sensations into a useable mental
representation of the world. Perception creates faces, melodies, works of art, illusions,
etc. out of the raw material of sensation.

Source: Coon, 1983.1

Examples of the perceptual process:

• the image formed on the retina is inverted and two dimensional, yet we see the world
the right way up and in three dimensions;

• if the head is turned, the eyes detect a constantly changing pattern of images, yet we
perceive things around us to have a set location, rather than move chaotically.

4.4 Decision Making

4.4.1 Having recognised coherent information from the stimuli reaching our senses, a
course of action has to be decided upon. In other words decision making occurs.

Decision making is the generation of alternative courses of action based on available

information, knowledge, prior experience, expectation, context, goals, etc. and selecting
one preferred option. It is also described as thinking, problem solving and judgement.

4.4.2 This may range from deciding to do nothing, to deciding to act immediately in a very
specific manner. A fire alarm bell, for instance, may trigger a well-trained sequence of
actions without further thought (i.e. evacuate); alternatively, an unfamiliar siren may
require further information to be gathered before an appropriate course of action can
be initiated.
4.4.3 We are not usually fully aware of the processes and information which we use to
make a decision. Tools can be used to assist the process of making a decision. For
instance, in aircraft maintenance engineering, many documents (e.g. maintenance
manuals, fault diagnosis manuals), and procedures are available to supplement the
basic decision making skills of the individual. Thus, good decisions are based on
knowledge supplemented by written information and procedures, analysis of
observed symptoms, performance indications, etc. It can be dangerous to believe
that existing knowledge and prior experience will always be sufficient in every
situation as will be shown in the section entitled ‘Information Processing Limitations’.
4.4.4 Finally, once a decision has been made, an appropriate action can be carried out. Our
senses receive feedback of this and its result. This helps to improve knowledge and
refine future judgement by learning from experience.

1. Coon, D. (1983) Introduction to Psychology (3rd edition). St. Paul, Minesota: West Publishing Co.

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4.5 Memory
4.5.1 Memory is critical to our ability to act consistently and to learn new things. Without
memory, we could not capture a ‘stream’ of information reaching our senses, or draw
on past experience and apply this knowledge when making decisions.

Memory can be considered to be the storage and retention of information, experiences

and knowledge, as well as the ability to retrieve this information.

4.5.2 Memory depends on three processes:

• registration - the input of information into memory;
• storage - the retention of information;
• retrieval - the recovery of stored information.
4.5.3 It is possible to distinguish between three forms of memory:
a) ultra short-term memory (or sensory storage);
b) short term memory (often referred to as working memory)
c) long term memory.
4.5.4 Ultra short-term memory has already been described when examining the role of
sensory stores. It has a duration of up to 2 seconds (depending on the sense) and is
used as a buffer, giving us time to attend to sensory input.
4.5.5 Short term memory receives a proportion of the information received into sensory
stores, and allows us to store information long enough to use it (hence the idea of
‘working memory’). It can store only a relatively small amount of information at one
time, i.e. 5 to 9 (often referred to as 7 ±2) items of information, for a short duration,
typically 10 to 20 seconds. As the following example shows, capacity of short term
memory can be enhanced by splitting information in to ‘chunks’ (a group of related

A telephone number, e.g. 01222555234, can be stored as 11 discrete digits, in which case
it is unlikely to be remembered. Alternatively, it can be stored in chunks of related
information, e.g. in the UK, 01222 may be stored as one chunk, 555 as another, and 234 as
another, using only 3 chunks and therefore, more likely to be remembered. In mainland
Europe, the same telephone number would probably be stored as 01 22 25 55 23 4, using
6 chunks. The size of the chunk will be determined by the individual’s familiarity with the
information (based on prior experience and context), thus in this example, a person from
the UK might recognise 0208 as the code for London, but a person from mainland Europe
might not.

4.5.6 The duration of short term memory can be extended through rehearsal (mental
repetition of the information) or encoding the information in some meaningful
manner (e.g. associating it with something as in the example above).

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4.5.7 The capacity of long-term memory appears to be unlimited. It is used to store

information that is not currently being used, including:
• knowledge of the physical world and objects within it and how these behave;
• personal experiences;
• beliefs about people, social norms, values, etc.;
• motor programmes, problem solving skills and plans for achieving various
• abilities, such as language comprehension.
4.5.8 Information in long-term memory can be divided into two types: (i) semantic and (ii)
episodic. Semantic memory refers to our store of general, factual knowledge about
the world, such as concepts, rules, one’s own language, etc. It is information that is
not tied to where and when the knowledge was originally acquired. Episodic
memory refers to memory of specific events, such as our past experiences (including
people, events and objects). We can usually place these things within a certain
context. It is believed that episodic memory is heavily influenced by a person’s
expectations of what should have happened, thus two people’s recollection of the
same event can differ.
4.6 Motor Programmes
If a task is performed often enough, it may eventually become automatic and the
required skills and actions are stored in long term memory. These are known as
motor programmes and are ingrained routines that have been established through
practice. The use of a motor programme reduces the load on the central decision
maker. An often quoted example is that of driving a car: at first, each individual action
such as gear changing is demanding, but eventually the separate actions are
combined into a motor programme and can be performed with little or no awareness.
These motor programmes allow us to carry out simultaneous activities, such as
having a conversation whilst driving.
4.7 Situation Awareness
4.7.1 Although not shown explicitly in Figure 8, the process of attention, perception and
judgement should result in awareness of the current situation.

Situation awareness is the synthesis of an accurate and up-to-date 'mental model' of one's
environment and state, and the ability to use this to make predictions of possible future

4.7.2 Situation awareness has traditionally been used in the context of the flight deck to
describe the pilot’s awareness of what is going on around him, e.g. where he is
geographically, his orientation in space, what mode the aircraft is in, etc. In the
maintenance engineering context, it refers to1:
• the perception of important elements, e.g. seeing loose bolts or missing parts,
hearing information passed verbally;
• the comprehension of their meaning, e.g. why is it like this? Is this how it should

1. Endsley, M.R. (1988) Design and Evaluation for Situation Awareness Enhancement. In: Proceedings of the Human
Factors Society 32nd Annual Meeting, pp. 97-101.

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• the projection of their status into the future, e.g. future effects on safety,
schedule, airworthiness.

An example is an engineer seeing (or perceiving) blue streaks on the fuselage. His
comprehension may be that the lavatory fill cap could be missing or the drainline leaking. If
his situation awareness is good, he may appreciate that such a leak could allow blue water
to freeze, leading to airframe or engine damage.

4.7.3 As with decision making, feedback improves situation awareness by informing us of

the accuracy of our mental models and their predictive power. The ability to project
system status backward, to determine what events may have led to an observed
system state, is also very important in aircraft maintenance engineering, as it allows
effective fault finding and diagnostic behaviour.
4.7.4 Situation awareness for the aircraft maintenance engineer can be summarised as:
• the status of the system the engineer is working on;
• the relationship between the reported defect and the intended rectification;
• the possible effect on this work on other systems;
• the effect of this work on that being done by others and the effect of their work on
this work.

This suggests that in aircraft maintenance engineering, the entire team needs to have
situation awareness - not just of what they are doing individually, but of their colleagues’
activities as well.

4.8 Information Processing Limitations

The basic elements of human information processing have now been explored. It is
important to appreciate that these elements have limitations. As a consequence, the
aircraft engineer, like other skilled professionals, requires support such as reference
to written material (e.g. manuals).
4.8.1 Attention and Perception
A proportion of ‘sensed’ data may be lost without being ‘perceived’. An example with
which most people are familiar is that of failing to perceive something which
someone has said to you, when you are concentrating on something else, even
though the words would have been received at the ear without any problem. The
other side of the coin is the ability of the information processing system to perceive
something (such as a picture, sentence, concept, etc.) even though some of the data
may be missing. The danger, however, is that people can fill in the gaps with
information from their own store of knowledge or experience, and this may lead to
the wrong conclusion being drawn.

Once we have formed a mental model of a situation, we often seek information which will
confirm this model and, not consciously, reject information which suggests that this model
is incorrect.

4.8.2 There are many well-known visual ‘illusions’ which illustrate the limits of human
perception. Figure 9 shows how the perceptual system can be misled into believing
that one line is longer than the other, even though a ruler will confirm that they are
exactly the same.

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Figure 9 The Muller-Lyer Illusion

4.8.3 Figure 10 illustrates that we can perceive the same thing quite differently (i.e. the
letter “B” or the number “13”). This shows the influence of context on our
information processing.

Figure 10 The importance of context.

4.8.4 In aviation maintenance it is often necessary to consult documents with which the
engineer can become very familiar. It is possible that an engineer can scan a
document and fail to notice that subtle changes have been made. He sees only what
he expects to see (expectation). To illustrate how our eyes can deceive us when
quickly scanning a sentence, read quickly the sentence below in Figure 11.

Figure 11 The effects of expectation
4.8.5 At first, most people tend to notice nothing wrong with the sentence. Our perceptual
system sub-consciously rejects the additional “THE”.

As an illustration of how expectation, can affect our judgement, the same video of a car
accident was shown to two groups of subjects. One group were told in advance that they
were to be shown a video of a car crash; the other were told that the car had been involved
in a ‘bump’. Both groups were asked to judge the speed at which the vehicles had collided.
The first group assessed the speed as significantly higher than the second group.

Source: Loftus, E.F. and Palmer, J.C., 19741

1. Loftus, E.F. and Palmer, J.C. (1974) Reconstruction of automobile destruction. Journal of Verbal Learning and Verbal
Behaviour, 13, pp. 585-9.

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4.8.6 Expectation can also affect our memory of events. The study outlined above was
extended such that subjects were asked, a week later, whether they recalled seeing
glass on the road after the collision. (There was no glass). The group who had been
told that they would see a crash, recalled seeing glass; the other group recalled
seeing no glass.
4.8.7 Decision Making, Memory, and Motor Programmes
a) Attention and perception shortcomings can clearly impinge on decision making.
Perceiving something incorrectly may mean that an incorrect decision is made,
resulting in an inappropriate action. Figure 8 also shows the dependence on
memory to make decisions. It was explained earlier that sensory and short-term
memory have limited capacity, both in terms of capacity and duration. It is also
important to bear in mind that human memory is fallible, so that information:
• may not be stored;
• may be stored incorrectly;
• may be difficult to retrieve.
4.8.8 All these may be referred to as forgetting, which occurs when information is
unavailable (not stored in the first place) or inaccessible (cannot be retrieved).
Information in short-term memory is particularly susceptible to interference, an
example of which would be trying to remember a part number whilst trying to recall
a telephone number.
4.8.9 It is generally better to use manuals and temporary aides-memoires rather than to
rely upon memory, even in circumstances where the information to be remembered
or recalled is relatively simple. For instance, an aircraft maintenance engineer may
think that he will remember a torque setting without writing it down, but between
consulting the manual and walking to the aircraft (possibly stopping to talk to
someone on the way), he may forget the setting or confuse it (possibly with a
different torque setting appropriate to a similar task with which he is more familiar).
Additionally, if unsure of the accuracy of memorised information, an aircraft
maintenance engineer should seek to check it, even if this means going elsewhere to
do so. Noting something down temporarily can avoid the risk of forgetting or
confusing information. However, the use of a personal note book to capture such
information on a permanent basis can be dangerous, as the information in it may
become out-of-date.

In the B737 double engine oil loss incident, the AAIB report stated:

“Once the Controller and fitter had got to T2 and found that this supportive material [Task
Cards and AMM extracts] was not available in the workpack, they would have had to return
to Base Engineering or to have gone over to the Line Maintenance office to get it. It would
be, in some measure, understandable for them to have a reluctance to recross the
exposed apron area on a winter’s night to obtain a description of what they were fairly
confident they knew anyway. However, during the course of the night, both of them had
occasion to return to the Base Maintenance hangar a number of times before the task had
been completed. Either could, therefore, have referred to or even drawn the task
descriptive papers before the job was signed off. The question that should be addressed,
therefore, is whether there might be any factors other than overconfidence in their
memories, bad judgement or idleness which would dispose them to pass up these
opportunities to refresh their memories on the proper and complete procedures.”

Source: AAIB, 19961

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Further Reading:
a) Campbell, R.D. and Bagshaw, M. (1999) Human Performance and Limitations in
Aviation (2nd edition). Oxford: Blackwell Scientific, Chapter 5.
b) Thom, T. (1999) The Air Pilot’s Manual Volume 6: Human Factors and Pilot
Performance (3rd edition). Shrewsbury: Airlife Publishing - Chapter 6.
c) Green, R.G., Muir, H., James, M., Gradwell, D. and Green, R.L. (1996) Human
Factors for Pilots (2nd edition). Aldershot: Ashgate - Sections 2a1 and 2a10.
d) Endsley, M.R., and Robertson, M.M. (1996) Team Situation Awareness in Aircraft
Maintenance. Phase VI progress report. Available from http://hfskyway.faa.gov
e) Endsley, M.R. (1995) A taxonomy of situation awareness errors. In R. Fuller, N.
Johnston, & N. McDonald (Eds.), Human Factors in Aviation Operations (pp.287-
292). Aldershot, England: Avebury Aviation, Ashgate Publishing Ltd.

5 Claustrophobia, Physical Access and Fear of Heights

Although not peculiar to aircraft maintenance engineering, working in restricted space

and at heights is a feature of this trade. Problems associated with physical access are
not uncommon. Maintenance engineers and technicians often have to access, and
work in, very small spaces (e.g. in fuel tanks), cramped conditions (such as beneath
flight instrument panels, around rudder pedals), elevated locations (on cherry-pickers
or staging), sometimes in uncomfortable climatic or environmental conditions (heat,
cold, wind, rain, noise). This can be aggravated by aspects such as poor lighting or
having to wear breathing apparatus. The physical environments associated with these
problems are examined further in Chapter 5.
5.1 Physical Access and Claustrophobia
5.1.1 There are many circumstances where people may experience various levels of
physical or psychological discomfort when in an enclosed or small space, which is
generally considered to be quite normal. When this discomfort becomes extreme, it
is known as claustrophobia.

Claustrophobia can be defined as abnormal fear of being in an enclosed space.

5.1.2 It is quite possible that susceptibility to claustrophobia is not apparent at the start of
employment. It may come about for the first time because of an incident when
working within a confined space, e.g. panic if unable to extricate oneself from a fuel
tank. If an engineer suffers an attack of claustrophobia, they should make their
colleagues and supervisors aware so that if tasks likely to generate claustrophobia
cannot be avoided, at least colleagues may be able to assist in extricating the
engineer from the confined space quickly, and sympathetically. Engineers should
work in a team and assist one another if necessary, making allowances for the fact
that people come in all shapes and sizes and that it may be easier for one person to
access a space, than another. However, this should not be used as an excuse for an
engineer who has put on weight, to excuse himself from jobs which he would
previously have been able to do with greater ease!

1. AAIB (1996) Report on the incident to a Boeing 737-400, G-OBMM near Daventry on 25 February 1995. Aircraft Accident
Report 3/96.

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5.2 Fear of Heights

5.2.1 Working at significant heights can also be a problem for some aircraft maintenance
engineers, especially when doing ‘crown’ inspections (top of fuselage, etc.). Some
engineers may be quite at ease in situations like these whereas others may be so
uncomfortable that they are far more concerned about the height, and holding on to
the access equipment, than they are about the job in hand. In such situations, it is very
important that appropriate use is made of harnesses and safety ropes. These will not
necessarily remove the fear of heights, but will certainly help to reassure the engineer
and allow him to concentrate on the task in hand. The FAA’s hfskyway website
provides practical guidance to access equipment when working at height. Ultimately,
if an engineer finds working high up brings on phobic symptoms (such as severe
anxiety and panic), they should avoid such situations for safety’s sake. However, as
with claustrophobia, support from team members can be helpful.

Shortly before the Aloha accident, during maintenance, the inspector needed ropes
attached to the rafters of the hangar to prevent falling from the aircraft when it was
necessary to inspect rivet lines on top of the fuselage. Although unavoidable, this would
not have been conducive to ensuring that the inspection was carried out meticulously (nor
was it, as the subsequent accident investigation revealed). The NTSB investigation report

“Inspection of the rivets required inspectors to climb on scaffolding and move along the
upper fuselage carrying a bright light with them; in the case of an eddy current inspection,
the inspectors needed a probe, a meter, and a light. At times, the inspector needed ropes
attached to the rafters of the hangar to prevent falling from the airplane when it was
necessary to inspect rivet lines on top of the fuselage. Even if the temperatures were
comfortable and the lighting was good, the task of examining the area around one rivet
after another for signs of minute cracks while standing on scaffolding or on top of the
fuselage is very tedious. After examining more and more rivets and finding no cracks, it is
natural to begin to expect that cracks will not be found.”

Please refer to Photograph A in Appendix A.

5.2.2 Managers and supervisors should attempt to make the job as comfortable and secure
as reasonably possible (e.g. providing knee pad rests, ensuring that staging does not
wobble, providing ventilation in enclosed spaces, etc.) and allow for frequent breaks
if practicable.
Further Reading:
a) Galaxy Scientific Corporation (1989) Human Factors Guide for Aviation
Maintenance, Chapter 5 Facility Design. Produced by Galaxy Scientific on behalf of
the FAA. Available from http://hfskyway.faa.gov
b) Galaxy Scientific Corporation (1993) Investigation of Ergonomic Factors Related to
Posture and Fatigue in the Inspection Environment. In Phase III. Progress Report,
Volume 1 Chapter 5. Produced by Galaxy Scientific on behalf of the FAA. Available
from http://hfskyway.faa.gov

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Chapter 3 Social Psychology

The previous chapter considered the abilities and limitations of the individual. This
chapter draws together issues relating to the social context in which the aircraft
maintenance engineer works. This includes the organisation in which he works and
how responsibilities may be delegated, motivation, and aspects of team working,
supervision and leadership.

1 The Social Environment

1.1 Aircraft maintenance engineers work within a “system”. As indicated in Figure 12,
there are various factors within this system that impinge on the aircraft maintenance
engineer, ranging from his knowledge, skills and abilities (discussed in the previous
chapter), the environment in which he works (dealt with in Chapter 5), to the culture
of the organisation for which he works. Even beyond the actual company he works
for, the regulatory requirements laid down for his trade clearly impact on his
behaviour. As will be seen in Chapter 8 on Human Error, all aspects of this system
may contribute towards errors that the engineer might make.

Knowledge, skills,
abilities and other

Immediate Facilities, weather, aircraft design and

environment configuration, component design, equipment/
tools/ parts, written/ computerised material,
tasks, time pressure, teamwork,

Supervision Planning, organising, prioritising, delegating,

instructing, OJT, feedback, performance,
management, team building

Organisation Philosophy, policies, procedures, processes,

selection, training, quality assurance

Safety regulation & safety

Regulation promotion, regulatory style

Economic climate, public

Wider perception of the
environment industry

Figure 12 The maintenance system. Source: Boeing, adapted by Baines, 20011

1.2 The vast majority of aircraft maintenance engineers work for a company, either
directly, or as contract staff. It is important to understand how the organisation in
which the engineer works might influence him. Every organisation or company
employing aircraft maintenance engineers will have different “ways of doing things”.

1. Baines, K. (2001) Training Material: Influences on the Maintenance System. UK Civil Aviation Authority.

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This is called the organisational culture. They will have their own company
philosophy, policies, procedures, selection and training criteria, and quality assurance
methods. Culture will be discussed further in a separate section in this chapter (5).
1.3 The impact of the organisation may be positive or negative. Organisations may
encourage their employees (both financially and with career incentives), and take
notice of problems that their engineers encounter, attempting to learn from these and
make changes where necessary or possible. On the negative side, the organisation
may exert pressure on its engineers to get work done within certain timescales and
within certain budgets. At times, individuals may feel that these conflict with their
ability to sustain the quality of their work. These organisational stresses may lead
to problems of poor industrial relations, high turnover of staff, increased absenteeism,
and most importantly for the aviation industry, more incidents and accidents due to
human error1.

2 Responsibility: Individual and Group

2.1 Being an aircraft maintenance engineer is a responsible job. Clearly, the engineer
plays a part in the safe and efficient passage of the travelling public when they use

If someone is considered responsible, they are liable to be called to account as being in

charge or control of, or answerable for something.

2.2 Within aircraft maintenance, responsibility should be spread across all those who play
a part in the activity. This ranges from the accountable manager who formulates
policy, through management that set procedures, to supervisors, teams of engineers
and individuals within those teams. Flight crew also play a part as they are responsible
for carrying out preflight checks and walkarounds and highlighting aircraft faults to
maintenance personnel.
2.3 Working as an Individual or as a Group
2.3.1 Traditionally, in the maintenance engineering environment, responsibility has been
considered in terms of the individual rather than the group or team. This is historical,
and has much to do with the manner in which engineers are licensed and the way in
which work is certified. This has both advantages and disadvantages. The main
advantage to individual responsibility is that an engineer understands clearly that one
or more tasks have been assigned to him and it is his job to do them (it can also be a
strong incentive to an engineer to do the work correctly knowing that he will be the
one held responsible if something goes wrong). The main disadvantage of any
emphasis upon personal responsibility, is that this may overlook the importance of
working together as a cohesive team or group to achieve goals.
2.3.2 In practice, aircraft maintenance engineers are often assigned to groups or teams in
the workplace. These may be shift teams, or smaller groups within a shift. A team
may be made up of various engineering trades, or be structured around aircraft types
or place of work (e.g. a particular hangar). Although distinct tasks may be assigned to
individuals within a team, the responsibility for fulfilling overall goals would fall on the
entire team. Team working is discussed in more detail in Section 6.

1. Green, R.G., Muir, H., James, M., Gradwell, D. and Green, R.L. (1996) Human Factors for Pilots (2nd edition). Aldershot:
Ashgate, p.74.

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2.4 Individual Responsibility

2.4.1 All aircraft maintenance engineers are skilled individuals having undertaken
considerable training. They work in a highly professional environment in the UK and
generally have considerable pride in their work and its contribution to air safety.
2.4.2 All individuals, regardless of their role, grade or qualifications should work in a
responsible manner. This includes not only Licensed Aircraft Engineers (LAEs), but
non-licensed staff. Airworthiness Notice No. 3 details the certification responsibilities
of LAEs. This document states that “The certifying engineer shall be responsible for
ensuring that work is performed and recorded in a satisfactory manner...”.1
Please refer to Photograph B in Appendix A.
2.4.3 Likewise, non-certifying technicians also have a responsibility in the maintenance
process. An organisation approved in accordance with JAR145 must establish the
competence of every person, whether directly involved in hands-on maintenance or
not. The CAA has previously ruled that an organisation can make provision on
maintenance records or work sheets for the mechanic(s) involved to sign for the
work. Whilst this is not the legally required certification under the requirements of
ANO Article 12 or JAR 145.50, it provides the traceability to those who were
involved in the job. The LAE is then responsible for any adjustment or functional test
and the required maintenance records are satisfied before making the legal
2.5 Group or Team Responsibility
2.5.1 Group responsibility has its advantages and disadvantages. The advantages are that
each member of the group ought to feel responsible for the output of that group, not
just their own output as an individual, and ought to work towards ensuring that the
whole ‘product’ is safe. This may involve cross-checking others’ work (even when not
strictly required), politely challenging others if you think that something is not quite
right, etc.
2.5.2 The disadvantage of group responsibility is that it can potentially act against safety,
with responsibility being devolved to such an extent that no-one feels personally
responsible for safety (referred to as diffusion of responsibility). Here, an individual,
on his own, may take action but, once placed within a group situation, he may not act
if none of the other group members do so, each member of the group or team
assuming that ‘someone else will do it’. This is expanded upon further in the section
on peer pressure later in this chapter (4).

Social psychologists have carried out experiments whereby a situation was contrived in
which someone was apparently in distress, and noted who came to help. If a person was
on their own, they were far more likely to help than if they were in a pair or group. In the
group situation, each person felt that it was not solely his responsibility to act and assumed
that someone else would do so.

2.5.3 Other recognised phenomena associated with group or team working and
responsibility for decisions and actions which aircraft maintenance engineers should
be aware of are:
2.5.4 Intergroup conflict in which situations evolve where a small group may act
cohesively as a team, but rivalries may arise between this team and others (e.g.
between engineers and planners, between shifts, between teams at different sites,
etc.). This may have implications in terms of responsibility, with teams failing to share

1. CAA (1999) CAP455: Airworthiness Notices. AWN3. UK Civil Aviation Authority, paragraph 3.4.

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responsibility between them. This is particularly pertinent to change of responsibility

at shift handovers, where members of the outgoing shift may feel no ‘moral’
responsibility for waiting for the incoming shift members to arrive and giving a verbal
handover in support of the written information on the workcards or task sheets,
whereas they might feel such responsibility when handing over tasks to others within
their own shift.
2.5.5 Group polarisation is the tendency for groups to make decisions that are more
extreme than the individual members’ initial positions. At times, group polarisation
results in more cautious decisions. Alternatively, in other situations, a group may
arrive at a course of action that is riskier than that which any individual member might
pursue. This is known as risky shift. Another example of group polarisation is
groupthink in which the desire of the group to reach unanimous agreement
overrides any individual impulse to adopt proper, rational (and responsible) decision-
making procedures.
2.5.6 Social loafing has been coined to reflect the tendency for some individuals to work
less hard on a task when they believe others are working on it. In other words, they
consider that their own efforts will be pooled with that of other group members and
not seen in isolation.
2.5.7 Responsibility is an important issue in aircraft maintenance engineering, and ought to
be addressed not only by licensing, regulations and procedures, but also by education
and training, attempting to engender a culture of shared, but not diffused,
Further Reading:
a) CAA (1999) CAP455: Airworthiness Notices. AWN3. UK Civil Aviation Authority.
b) Scoble, R. (1993) Aircraft Maintenance Production And Inspection: Team Work +
Empowerment + Process Simplification = Quality. In: Proceedings of the Eighth
Meeting on Human Factors Issues in Aircraft Maintenance and Inspection.
Available from http://hfskyway.faa.gov
c) Gross, R. (1996) Psychology: The Science of Mind and Behaviour (3rd edition).
London: Hodder & Stoughton - Chapter 20 ‘Social Influence’.

3 Motivation and De-motivation

3.1 Motivated behaviour is goal-directed, purposeful behaviour, and no human behaviour

occurs without some kind of motivation underpinning it. In aircraft maintenance,
engineers are trained to carry out the tasks within their remit. However, it is largely
their motivation which determines what they actually do in any given situation. Thus,
“motivation reflects the difference between what a person can do and what he will

Motivation can be thought of as a basic human drive that arouses, directs and sustains all
human behaviour. Generally we say a person is motivated if he is taking action to achieve

3.2 Motivation is usually considered to be a positive rather than a negative force in that it
stimulates one to achieve various things. However just because someone is
motivated, this does not mean to say that they are doing the right thing. Many

1. Hawkins, F.H. (1993) Human Factors in Flight (2nd edition). Aldershot: Ashgate, p. 133.

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criminals are highly motivated for instance. Motivation is difficult to measure and
predict. We are all motivated by different things, for example, an artist might strive
over many months to complete a painting that he may never sell, whereas a
businessman may forfeit all family life in pursuit of financial success.
3.3 With respect to aviation safety, being appropriately motivated is vital. Ideally, aircraft
maintenance engineers ought to be motivated to work in a safe and efficient manner.
However, many factors may cause conflicting motivations to override this ideal. For
instance, the motivation of some financial bonus, or de-motivation of working
outdoors in extreme cold weather might lead to less consideration of safety and
increase the likelihood of risk taking, corner cutting, violating procedures and so on.
Aircraft maintenance engineers should be aware of conflicting motivations that
impinge on their actions and attempt to examine their motivations for working in a
certain way.
3.4 Maslow’s Hierarchy of Needs
3.4.1 Possibly one of the most well known theories which attempts to describe human
motivation is Maslow’s hierarchy of needs. Maslow considered that humans are
driven by two different sets of motivational forces:
• those that ensure survival by satisfying basic physical and psychological needs;
• those that help us to realise our full potential in life known as self-actualisation
needs (fulfilling ambitions, etc.).
3.4.2 Figure 13 shows the hypothetical hierarchical nature of the needs we are motivated
to satisfy. The theory is that the needs lower down the hierarchy are more primitive
or basic and must be satisfied before we can be motivated by the higher needs. For
instance, you will probably find it harder to concentrate on the information in this
document if you are very hungry (as the lower level physiological need to eat
predominates over the higher level cognitive need to gain knowledge). There are
always exceptions to this, such as the mountain climber who risks his life in the name
of adventure. The higher up the hierarchy one goes, the more difficult it becomes to
achieve the need. High level needs are often long-term goals that have to be
accomplished in a series of steps.

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Figure 13 Maslow’s hierarchy of needs. Source: Maslow, 19541

3.4.3 An aircraft maintenance engineer will fulfil lower level needs by earning money to buy
food, pay for a home and support a family. They may well be motivated by middle
level needs in their work context (e.g. social groups at work, gaining status and
recognition). It is noteworthy that for shift workers, tiredness may be a more powerful
motivator than a higher order need (such as personal satisfaction to get the job done
in time or accurately).

An interesting experiment on motivation was carried out in 1924 at the Hawthorne Works
of the Western Electric Company in Chicago. Here, the management altered various
factors such as rest periods, lighting levels, working hours, etc. and each time they did so,
performance improved, even when the apparent improvements were taken away! This
suggested that it was not the improvements themselves which were causing the
increased production rates, but rather the fact that the staff felt that management were
taking notice of them and were concerned for their welfare. This phenomenon is known as
the Hawthorne effect.

1. Maslow, A. (1954) Motivation and personality. New York: Harper and Row.

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3.5 De-motivation
3.5.1 Highly motivated people tend to show the following characteristics:
• high performance and results being consistently achieved;
• the energy, enthusiasm and determination to succeed;
• unstinting co-operation in overcoming problems;
• willingness to accept responsibility;
• willingness to accommodate change.
3.5.2 People who are de-motivated lack motivation, either intrinsically or through a failure
of their management to motivate the staff who work for them. De-motivated people
tend to demonstrate the following characteristics:
• apathy and indifference to the job, including reduced regard for safety whilst
• a poor record of time keeping and high absenteeism;
• an exaggeration of the effects/difficulties encountered in problems, disputes and
• a lack of co-operation in dealing with problems or difficulties;
• unjustified resistance to change.
3.5.3 However, care should be taken when associating these characteristics with lack of
motivation, since some could also be signs of stress.
3.5.4 There is much debate as to the extent to which financial reward is a motivator. There
is a school of thought which suggests that whilst lack of financial reward is a de-
motivator, the reverse is not necessarily true. The attraction of the extra pay offered
to work a ‘ghoster’1 can be a strong motivator for an individual to ignore the dangers
associated with working when tired.
3.5.5 The motivating effects of job security and the de-motivating impact of lack of job
security is also an area that causes much debate. The ‘hire and fire’ attitude of some
companies can, potentially, be a major influence upon safety, with real or perceived
pressure upon individuals affecting their performance and actions. It is important that
maintenance engineers are motivated by a desire to ensure safety (Maslow’s ‘self
esteem/self respect’), rather than by a fear of being punished and losing their job
(Maslow’s ‘security’). It is possible that the “can do” culture, which is evident in some
areas of the industry, may be generated by the expectancy that if individuals do not
‘deliver’, they will be punished (or even dismissed) and, conversely, those who do
‘deliver’ (whether strictly by the book or not, finding ways around lack of time, spares
or equipment) are rewarded and promoted. This is not motivation in the true sense
but it has its roots in a complex series of pressures and drives and is one of the major
influences upon human performance and human error in maintenance engineering.
Further Reading:
a) Hawkins, F.H. (1993) Human Factors in Flight (2nd edition). Aldershot: Ashgate -
Chapter 6.
b) Gross, R. (1996) Psychology: The Science of Mind and Behaviour (3rd edition).
London: Hodder and Stoughton - Chapter 5.

1. a back-to-back shift

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4 Peer Pressure

4.1 In the working environment of aircraft maintenance, there are many pressures
brought to bear on the individual engineer. We have already discussed the influence
of the organisation, of responsibility and motivational drives. In addition to these,
there is the possibility that the aircraft maintenance engineer will receive pressure at
work from those that work with him. This is known as peer pressure.

Peer pressure is the actual or perceived pressure which an individual may feel, to conform
to what he believes that his peers or colleagues expect.

4.2 For example, an individual engineer may feel that there is pressure to cut corners in
order to get an aircraft out by a certain time, in the belief that this is what his
colleagues would do under similar circumstances. There may be no actual pressure
from management to cut corners, but subtle pressure from peers, e.g. taking the
form of comments such as “You don’t want to bother checking the manual for that.
You do it like this…” would constitute peer pressure.
4.3 Peer pressure thus falls within the area of conformity. Conformity is the tendency to
allow one’s opinions, attitudes, actions and even perceptions to be affected by
prevailing opinions, attitudes, actions and perceptions.
4.4 Experiments in Conformity
4.4.1 Asch1 carried out several experiments investigating the nature of conformity, in which
he asked people to judge which of lines A, B & C was the same length as line X. (see
Figure 14). He asked this question under different conditions:
• where the individual was asked to make the judgement on his own;
• where the individual carried out the task after a group of 7-9 confederates of Asch
had all judged that line A was the correct choice. Of course, the real participant did
not know the others were “stooges”


(B is the same length as X)

Figure 14 An experiment to illustrate conformity. Source: Asch, 1951

4.4.2 In the first condition, very few mistakes were made (as would be expected of such a
simple task with an obvious answer). In the latter condition, on average, participants
gave wrong answers on one third of the trials by agreeing with the confederate
majority. Clearly, participants yielded to group pressure and agreed with the incorrect
‘group’ finding (however, it is worth mentioning that there were considerable

1. Asch, S. (1951) Effects of Group Pressure upon the Modification and Distortion of Judgement. in Groups, Leadership and
Men (Ed.) Guetzkow, M H. (1951). Pittsburgh: Carnegie

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individual differences: some participants never conformed, and some conformed all
the time).
4.4.3 Further research indicated that conformity does not occur with only one confederate
(as then it is a case of ‘my word against yours’). However, it is necessary to have only
three confederates to one real participant to attain the results that Asch found with 7-
9 confederates.
4.4.4 The degree to which an individual’s view is likely to be affected by conformity or peer
pressure, depends on many factors, including:
• culture (people from country x tend to conform more than those from country y);
• gender (men tend to conform less than women);
• self-esteem (a person with low self-esteem is likely to conform more);
• familiarity of the individual with the subject matter (a person is more likely to
conform to the majority view if he feels that he knows less about the subject
matter than they do);
• the expertise of the group members (if the individual respects the group or
perceives them to be very knowledgeable he will be more likely to conform to their
• the relationship between the individual and group members (conformity increases
if the individual knows the other members of the group, i.e. it is a group of peers).
4.5 Countering Peer Pressure and Conformity
4.5.1 The influence of peer pressure and conformity on an individual’s views can be
reduced considerably if the individual airs their views publicly from the outset.
However, this can be very difficult: after Asch’s experiments, when asked, many
participants said they agreed with the majority as they did not want to appear different
or to look foolish.
4.5.2 Conformity is closely linked with ‘culture’ (described in the next section). It is highly
relevant in the aircraft maintenance environment where it can work for or against a
safety culture, depending on the attitudes of the existing staff and their influence over
newcomers. In other words, it is important for an organisation to engender a positive
approach to safety throughout their workforce, so that peer pressure and conformity
perpetuates this. In this instance, peer pressure is clearly a good thing. Too often,
however, it works in reverse, with safety standards gradually deteriorating as shift
members develop practices which might appear to them to be more efficient, but
which erode safety. These place pressure, albeit possibly unwittingly, upon new
engineers joining the shift, to do likewise.
Further Reading:
a) Gross, R. (1996) Psychology. The Science of Mind and Behaviour (3rd edition).
London: Hodder and Stoughton - Chapter 20.

5 Culture Issues

5.1 There can be a degree of mistrust of anything new in the workplace, (e.g. an individual
joining a company whose expertise has not yet been proven, or contracting out
maintenance to another company, etc.). There may be a tendency for groups within
organisation and the organisation itself to think that their own methods are the best

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and that others are not as good. This viewpoint is known as the group’s or
organisation’s culture.

The culture of an organisation can be described as ‘the way we do things here’. It is a group
or company norm.

5.2 Figure 15 indicates that there can be an overall organisational culture, and a number
of different ‘sub-cultures’, such as safety culture, professional/technical culture, etc.
It is possible for cultural differences to exist between sites or even between shifts
within the same organisation. The prevailing culture of the industry as a whole also
influences individual organisations.

Safety Culture
Safety Culture
Safety Culture
Culture of
shifts /of
Culture shifts
// work
work groups
Technical Culture
Technical Culture Organisation’s
Technical Culture
Culture of
company of
sites sites
Business Culture
Business Culture Culture ofofthe
Culture the Aircraft
theAircraft Maintenance
Aircraft Maintenance
Business Culture
Engineering Industry
Engineering Industry as
as a
Industry as a Whole

Figure 15 The influences on an organisation’s culture

5.3 Culture is not necessarily always generated or driven from the top of an organisation
(as one might think), but this is the best point from which to influence the culture.
5.4 Safety Culture
5.4.1 The ICAO Human factors Digest No. 10, “Human Factors, Management and
Organisation” (Circular 247), discusses corporate culture and the differences
between safe and unsafe corporate cultures.

ICAO HF Digest 10 describes a safety culture as “a set of beliefs, norms, attitudes, roles
and social and technical practices concerned with minimising exposure of employees,
managers, customers and members of the general public to conditions considered
dangerous or hazardous”

5.4.2 Gary Eiff from Purdue University discusses safety culture in his paper “Organizational
Culture and its Effect on Safety”1. He suggests that “A safety culture exists only
within an organisation where each individual employee, regardless of their position,
assumes an active role in error prevention”, stressing that “Safety cultures do not
…spring to life simply at the declaration of corporate leaders”.

1. Eiff, G. (1998) Organizational Culture and its Effect on Safety in 12th Symposium on Human Factors in Aviation

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5.4.3 The culture of an organisation can best be judged by what is done rather than by what
is said. Organisations may have grand ‘mission statements’ concerning safety but this
does not indicate that they have a good safety culture unless the policies preached at
the top are actually put into practise at the lower levels. It may be difficult to
determine the safety culture of an organisation by auditing the procedures and
paperwork; a better method is to find out what the majority of the staff actually
believe and do in practice.

A method for measuring attitudes to safety has been developed by the Health and Safety
Executive utilising a questionnaire approach. Examples of the statements which
employees are asked the extent to which they agree are:

• It is necessary to bend some rules to achieve a target;

• Short cuts are acceptable when they involve little or no risk;
• I often come across situations with which I am unfamiliar;
• I sometimes fail to understand which rules apply;
• I am not given regular break periods when I do repetitive and boring jobs;
• There are financial rewards to be gained from breaking the rules.

The results are scored and analysed to give an indication of the safety culture of the
organisation, broken down according to safety commitment, supervision, work conditions,
logistic support, etc. In theory, this enables one organisation to be objectively compared
with another.

5.4.4 Professor James Reason describes the key components of a safety culture1,
summarised as follows:
• The ‘engine’ that continues to propel the system towards the goal of maximum
safety health, regardless of the leadership’s personality or current commercial
• Not forgetting to be afraid;
• Creating a safety information system that collects, analyses and disseminates
information from incidents and near-misses as well as from regular proactive
checks on the system’s vital signs;
• A good reporting culture, where staff are willing to report near-misses;
• A just culture - an atmosphere of trust, where people are encouraged, even
rewarded, for providing essential safety related information - but in which they are
clear about where the line must be drawn between acceptable and unacceptable
• A flexible culture;
• Respect for the skills, experience and abilities of the workforce and first line
• Training investment;
• A learning culture - the willingness and the competence to draw the right
conclusions from its safety information system, and the will to implement major
reforms when their need is indicated.

1. Reason, J.T. (1997) Managing the Risks of Organisational Accidents. Aldershot: Ashgate.

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5.5 Social Culture

The influence of social culture (an individual’s background or heritage) can be
important in determining how an individual integrates into an organisational culture.
The way an individual behaves outside an organisation is likely to have a bearing on
how they behave within it. Internal pressures and conflicts within groups at work can
be driven by underlying social cultural differences (e.g. different nationalities, different
political views, different religious beliefs, etc.). This is an extremely complex subject,
however, and in-depth discussion is beyond the scope of this text.

Whilst safety culture has been discussed from the organisational perspective, the
responsibility of the individual should not be overlooked. Ultimately, safety culture is an
amalgamation of the attitude, beliefs and actions of all the individuals working for the
organisation and each person should take responsibility for their own contribution towards
this culture, ensuring that it is a positive contribution rather than a negative one.

Further Reading:
a) Reason, J. (1997) Managing the Risks of Organisational Accidents. Aldershot:
b) Human Factors Digest No. 10. (1993) Human Factors, Management and
Organisation. (ICAO Circular 247)
c) Health and Safety Executive (1995) Improving Compliance with Safety Procedures:
Reducing Industrial Violations. London: HSE.

6 Team Working

The responsibility of aircraft maintenance engineers within teams has been discussed
in section 2 and the influence of peers on the behaviour of the individual highlighted
in section 4. This section looks in more detail at team working in aircraft maintenance.
6.1 The Concept of A Team
6.1.1 A lot has been written on the concept of a team, and it is beyond the scope of this
document to give anything but a flavour of this.

Whereas individualism encourages independence, teams are associated with

interdependence and working together in some way to achieve one or more goals.

6.1.2 Teams may comprise a number of individuals working together towards one shared
goal. Alternatively, they may consist of a number of individuals working in parallel
to achieve one common goal. Teams generally have a recognised leader and one or
more follower(s). Teams need to be built up and their identity as a team needs to be
maintained in some way.

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6.1.3 A team could be a group of engineers working on a specific task or the same aircraft,
a group working together on the same shift, or a group working in the same location
or site. There are natural teams within the aircraft maintenance environment. The
most obvious is the supervisor and the engineers working under his supervision. A
team could also be a Licensed Aircraft Engineer (LAE) and unlicensed engineers
working subject to his scrutiny. A team may well comprise engineers of different
technical specialities (e.g. sheet/metal structures, electrical/electronics/avionics,
hydraulics, etc.).
6.1.4 There has been a great deal of work carried out on teamwork, in particular “Crew
Resource Management (CRM)” in the cockpit context and, more recently,
“Maintenance Resource Management (MRM)” in the maintenance context. The
ICAO Human Factors Digest No. 12 “Human Factors in Aircraft Maintenance and
Inspection” (ICAO Circular 253), includes a Chapter on team working, to which the
reader is directed for further information. MRM is addressed separately (section 8)
since it covers more than just teamwork.
6.2 Some Advantages and Disadvantages of Team Working
6.2.1 The discussion on motivation suggests that individuals need to feel part of a social
group. In this respect, team working is advantageous. However, the work on
conformity suggests that they feel some pressure to adhere to a group’s views,
which may be seen as a potential disadvantage.
6.2.2 Working as part of a team has a number of potential benefits which include:
• individuals can share resources (knowledge, tools, etc.);
• they can discuss problems and arrive at shared solutions;
• they can check each others’ work (either “officially” or “unofficially”).
6.2.3 Teams can be encouraged to take ownership of tasks at the working level. This
gives a team greater responsibility over a package of work, rather than having to keep
referring to other management for authorisation, support or direction. However,
groups left to their own devices need proper leadership (discussed in section 7).
Healthy competition and rivalry between teams can create a strong team identity
and encourage pride in the product of a team. Team identity also has the advantage
that a group of engineers know one another’s capabilities (and weaknesses).
6.2.4 As noted in section 2, if work has to be handed over to another group or team (e.g.
shift handover), this can cause problems if it is not handled correctly. If one team of
engineers consider that their diligence (i.e. taking the trouble to do something
properly and carefully) is a waste of time because an incoming team’s poor
performance will detract from it, then it is likely that diligence will become more and
more rare over time.
6.3 Important Elements of Team Working
For teams to function cohesively and productively, team members need to have or
build up certain interpersonal and social skills. These include communication, co-
operation, co-ordination and mutual support
6.3.1 Communication
Communication is essential for exchanging work-related information within the team.
For example, a team leader must ensure that a team member has not just heard an
instruction, but understood what is meant by it. A team member must highlight
problems to his colleagues and/or team leader. Furthermore, it is important to listen
to what others say. This is covered in greater depth in Chapter 7.

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6.3.2 Co-operation
‘Pulling together’ is inherent in the smooth running of a team. Fairness and
openness within the team encourage cohesiveness and mutual respect.
Disagreements must be handled sensitively by the team leader.
6.3.3 Co-ordination
Co-ordination is required within the team to ensure that the team leader knows what
his group members are doing. This includes delegation of tasks so that all the
resources within the team are utilised. Delegated tasks should be supervised and
monitored as required. The team leader must ensure that no individual is assigned a
task beyond his capabilities. Further important aspects of co-ordination are
agreement of responsibilities (i.e. who should accomplish which tasks and within
what timescale), and prioritisation of tasks.
6.3.4 Mutual Support
a) Mutual support is at the heart of the team’s identity. The team leader must
engender this in his team. For instance, if mistakes are made, these should be
discussed and corrected constructively.
b) It is worth noting that in many companies, line engineers tend to work as
individuals whereas base engineers tend to work in teams. This may be of
significance when an engineer who normally works in a hangar, finds himself
working on the line, or vice versa. This was the case in the Boeing 737 incident1
involving double engine oil pressure loss, where the Base Controller took over a
job from the Line Maintenance engineer, along with the line maintenance
paperwork. The line maintenance paperwork is not designed for recording work
with a view to a handover, and this was a factor when the job was handed over
from the Line engineer to the Base Controller.
Further Reading:
a) Human Factors Digest No. 12 (1995) Human Factors in Aircraft Maintenance and
Inspection. (ICAO Circular 253)
b) Human Factors Digest No. 3 (1991) Training of Operational Personnel in Human
Factors. (ICAO Circular 227)
c) Sian, B., Robertson, M., Watson, J. (1998) Maintenance Resource Management
Handbook. Available from http://hfskyway.faa.gov

7 Management, Supervision and Leadership

The previous section made frequent reference to the team leader. Management,
supervision and leadership are all skills that a team leader requires. Of course,
management is also a function within an organisation (i.e. those managers
responsible for policy, business decisions, etc.), as is the supervisor (i.e. in an official
role overseeing a team).

Managers and supervisors have a key role to play in ensuring that work is carried out
safely. It is no good instilling the engineers and technicians with ‘good safety practice’
concepts, if these are not supported by their supervisors and managers.

1. AAIB (1996) Report on the incident to a Boeing 737-400, G-OBMM near Daventry on 25 February 1995. Aircraft Accident
report 3/96.

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7.1 The Management Role

Line Managers, particularly those working as an integral part of the ‘front line’
operation, may be placed in a situation where they may have to compromise between
commercial drivers and ‘ideal’ safety practices (both of which are passed down from
‘top management’ in the organisation). For example, if there is a temporary staff
shortage, he must decide whether maintenance tasks can be safely carried out with
reduced manpower, or he must decide whether an engineer volunteering to work a
“ghoster” to make up the numbers will be able to perform adequately. The adoption
of Safety Management Principles1 may help by providing Managers with techniques
whereby they can carry out a more objective assessment of risk.
7.2 The Supervisory Role
7.2.1 Supervision may be a formal role or post (i.e. a Supervisor), or an informal
arrangement in which a more experienced engineer ‘keeps an eye on’ less
experienced staff. The Supervisor is in a position not only to watch out for errors
which might be made by engineers and technicians, but will also have a good
appreciation of individual engineer’s strengths and weaknesses, together with an
appreciation of the norms and safety culture of the group which he supervises. It is
mainly his job to prevent unsafe norms from developing, and to ensure that good
safety practices are maintained. There can be a risk however, that the Supervisor
becomes drawn down the same cultural path as his team without realising. It is good
practice for a Supervisor to step back from the day-to-day work on occasion and to try
to look at his charges’ performance objectively.
7.2.2 It can be difficult for supervisory and management staff to strike the right balance
between carrying out their supervisory duties and maintaining their engineering skills
and knowledge (and appropriate authorisations), and they may get out of practice. In
the UK Air Accidents Investigation Branch (AAIB) investigation reports of the BAC 1-
11, A320 and B737 incidents, a common factor was: “Supervisors tackling long
duration, hands-on involved tasks2”. In the B737 incident, the borescope inspection
was carried out by the Base Controller, who needed to do the task in order to retain
his borescope authorisation. Also, there is unlikely to be anyone monitoring or
checking the Supervisor, because:
• of his seniority;
• he is generally authorised to sign for his own work (except, of course, in the case
where a duplicate inspection is required);
• he may often have to step in when there are staff shortages and, therefore, no
spare staff to monitor or check the tasks;
• he may be ‘closer’ (i.e. more sensitive to) to any commercial pressures which may
exist, or may perceive that pressure to a greater extent than other engineers.
7.2.3 It is not the intention to suggest that supervisors are more vulnerable to error; rather
that the circumstances which require supervisors to step in and assist tend to be
those where several of the ‘defences’ (see Chapter 8 - error) have already failed and
which may result in a situation which is more vulnerable to error.
7.3 Characteristics of a Leader
7.3.1 There are potentially two types of leader in aircraft maintenance: the person officially
assigned the team leader role (possibly called the Supervisor), an individual within a

1. CAA (2001) CAP712: Safety Management Systems for Commercial Air Transport Operations. UK Civil Aviation Authority.
2. King, D. (1998) Learning lessons the (not quite so) hard way; Incidents, the route to human factors in engineering. In:
Proceedings of the 12th symposium on human factors in aviation maintenance.

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group that the rest of the group tend to follow or defer to (possibly due to a dominant
personality, etc.). Ideally of course, the official team leader should also be the person
the rest of the group defer to.

A leader in a given situation is a person whose ideas and actions influence the thought and
the behaviour of others.

7.3.2 A good leader in the maintenance engineering environment needs to possess a

number of qualities:
• Motivating his team;
• Reinforcing good attitudes and behaviour;
• Demonstrating by example;
• Maintaining the group;
• Fulfilling a management role.
7.3.3 These will now be examined in a little more detail:
7.3.4 Motivating the Team
Just as the captain of a football team motivates his fellow players, the leader of a
maintenance team must do likewise. This can be done by ensuring that the goals or
targets of the work which need to be achieved are clearly communicated and
manageable. For instance, the team leader would describe the work required on an
aircraft within a shift. He must be honest and open, highlighting any potential
problems and where appropriate encouraging team solutions.
7.3.5 Reinforcing Good Attitudes and Behaviour
When team members work well (i.e. safely and efficiently), this must be recognised
by the team leader and reinforced. This might be by offering a word of thanks for hard
work, or making a favourable report to senior management on an individual. A good
leader will also make sure that bad habits are eliminated and inappropriate actions are
constructively criticised.
7.3.6 Demonstrating by Example
A key skill for a team leader is to lead by example. This does not necessarily mean
that a leader must demonstrate that he is adept at a task as his team (it has already
been noted that a Supervisor may not have as much opportunity to practise using
their skills). Rather, he must demonstrate a personal understanding of the activities
and goals of the team so that the team members respect his authority. It is particularly
important that the team leader establishes a good safety culture within a team
through his attitude and actions in this respect.
7.3.7 Maintaining the Group
Individuals do not always work together as good teams. It is part of the leader’s role
to be sensitive to the structure of the team and the relationships within it. He must
engender a ‘team spirit’ where the team members support each other and feel
responsible for the work of the team. He must also recognise and resolve disputes
within the team and encourage co-operation amongst its members.
7.3.8 Fulfilling a Management Role
The team leader must not be afraid to lead (and diplomatically making it clear when
necessary that there cannot be more than one leader in a team). The team leader is
the link between higher levels of management within the organisation and the team

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members who actually work on the aircraft. He is responsible for co-ordinating the
activities of the team on a day-to-day basis, which includes allocation of tasks and
delegation of duties. There can be a tendency for team members to transfer some of
their own responsibilities to the team leader, and he must be careful to resist this.

Skilled management, supervision and leadership play a significant part in the attainment of
safety and high quality human performance in aircraft maintenance engineering.

7.3.9 In terms of the relationship between managers, supervisors and engineers, a ‘them
and us’ attitude is not particularly conducive to improving the safety culture of an
organisation. It is important that managers, supervisors, engineers and technicians all
work together, rather than against one another, to ensure that aircraft maintenance
improves airworthiness.
Further Reading:
a) Armstrong, M. (1998) Managing People: A Practical Guide for Line Managers.
Kogan Page.
b) Mackreath, J. (1998) The Introduction In The Royal Air Force Of Self-Supervision
Procedures In Aircraft Maintenance. In: Meeting 12: The 12th Symposium on
Human Factors in Aviation Maintenance. London. Available from http://
c) Gross, R. (1996) Psychology: The Science of Mind and Behaviour (3rd edition)
London: Hodder and Stoughton - Chapter 20.

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8 Maintenance Resource Management (MRM)

8.1 Although not part of the JAR66-9 syllabus, Maintenance Resource Management
(MRM) is nevertheless included as a specific topic because it is implicit in many of the
areas covered in this chapter, such as team working, communication, responsibility,
shift handovers. The discussion of MRM in this text is intended only as an
introduction to the basic concepts. For in-depth information concerning MRM, the
reader is referred to the “Maintenance Resource Management Handbook1”
produced on behalf of the FAA.

MRM is not about addressing the individual human factors of the engineer or his manager;
rather, it looks at the larger system of human factors concerns involving engineers,
managers and others, working together to promote safety.

Source: Taylor, J., 19982

8.2 The term ‘Maintenance Resource Management’ became better known after the
Aloha accident in 1988, when researchers took Crew Resource Management (CRM)
concepts and applied them to the aircraft maintenance environment. CRM concerns
the process of managing all resources in and out of the cockpit to promote safe flying
operations. These resources not only include the human element, but also
mechanical, computer and other supporting systems. MRM has many similarities to
CRM, although the cockpit environment and team is somewhat different from that
found in aircraft maintenance. The FAA MRM handbook highlights the main
differences between CRM and MRM, and these are summarised in Table 2.

1. Sian, B., Robertson, M., Watson, J. (1998) Maintenance Resource Management handbook. Available from http://
2. Taylor, J. (1998) Evaluating the effectiveness of MRM. In: Proceedings of the 12th symposium on human factors in
aviation maintenance. Available from http://hfskyway.faa.gov

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Table 2 Examples of the Differences Between CRM and MRM Highlighted in the
FAA Maintenance Resource Management Handbook

Human error

Errors tend to be ‘active’ in that their The consequences of an engineer’s error are often
consequences follow on immediately not immediately apparent, and this has
after the error. implications for training for error avoidance.


Much of flight operations are Maintenance operations tend to be characterised

characterised by synchronous, “face-to- by “asynchronous” communications such as
face” communications, or immediate technical manuals, memos, Advisory Circulars,
voice communications (e.g. with ATC) Airworthiness Directives, workcards and other
over the radio. non-immediate formats. Much of the information
transfer tends to be of a non-verbal nature.

“Team” composition

Flight crews are mostly homogenous by Maintenance staff are diverse in their range of
nature, in that they are similar in experiences and education and this needs to be
education level and experience, relative taken into account in a MRM programme.
to their maintenance counterparts.


Flight deck crew team size is small - two Maintenance operations are characterised by large
or three members; although the wider teams working on disjointed tasks, spread out over
team is obviously larger (i.e. flight deck a hangar. In addition, a maintenance task may
crew + cabin crew, flight crew + ATC, require multiple teams (hangar, planning
ground crew, etc.) department, technical library, management) each
with their own responsibilities. Therefore MRM
places equal emphasis on inter-team teamwork

Situation awareness

The flight environment is quickly The maintenance environment, thought hectic,

changing, setting the stage for the changes slowly relative to flight operations. In
creation of active failures. Situation terms of situation awareness, engineers must
awareness in CRM is tailored to avoid have the ability to extrapolate the consequences of
these errors; Line Oriented Flight Training their errors over hours, days or even weeks. To do
(LOFT) simulations provide flight crews this, the situation awareness cues that are taught
with real-time, simulations to improve must be tailored to fit the maintenance
future situation awareness. environment using MRM-specific simulations.


Similar to teamwork issues, leadership Because supervisors or team leaders routinely

skills in CRM often focus mainly on intra- serve as intermediaries among many points of the
team behaviours or ‘how to lead the organisation, engineer leaders must be skilled not
team’, as well as followership skills. Inter- only in intra-team behaviours, but in handling team
team interaction is somewhat limited ‘outsiders’ (personnel from other shifts, managers
during flight. outside the immediate workgroup, etc.) during any
phase of the maintenance problem. These
outsiders also vary widely in experience,
mannerisms, etc. A good MRM programme should
take these into account.

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8.3 One of the early MRM training programmes was developed by Gordon Dupont for
Transport Canada1. It introduced “The Dirty Dozen”, which are 12 areas of potential
problems in human factors. A series of posters has been produced, one for each of
these headings, giving a few examples of good practices or “safety nets” which
ought to be adopted. These are summarised in Table 3 and addressed in most
maintenance human factors programmes.

Table 3 Examples of Potential Human Factors Problems from the “Dirty Dozen”

Potential Solutions

1. Lack of Use logbooks, worksheets, etc. to communicate and remove doubt.

communication Discuss work to be done or what has been completed.
Never assume anything.

2. Complacency Train yourself to expect to find a fault.

Never sign for anything you didn’t do [or see done].

3. Lack of Get training on type.

knowledge Use up-to-date manuals.
Ask a technical representative or someone who knows.

4. Distraction Always finish the job or unfasten the connection.

Mark the uncompleted work.
Lockwire where possible or use torqueseal.
Double inspect by another or self.
When you return to the job, always go back three steps.
Use a detailed check sheet.

5. Lack of Discuss what, who and how a job is to be done.

teamwork Be sure that everyone understands and agrees.

6. Fatigue Be aware of the symptoms and look for them in yourself and others.
Plan to avoid complex tasks at the bottom of your circadian rhythm.
Sleep and exercise regularly.
Ask others to check your work.

7. Lack of parts Check suspect areas at the beginning of the inspection and AOG the
required parts.
Order and stock anticipated parts before they are required.
Know all available parts sources and arrange for pooling or loaning.
Maintain a standard and if in doubt ground the aircraft.

8. Pressure Be sure the pressure isn’t self-induced.

Communicate your concerns.
Ask for extra help.
Just say ‘No’.

9. Lack of If it’s not critical, record it in the journey log book and only sign for what is
assertiveness serviceable.
Refuse to compromise your standards.

1. Dupont, G. (1997) The Dirty Dozen Errors in Maintenance. In: proceedings of the 11th Symposium on Human Factors in
Aviation Maintenance. Available from http://hfskyway.faa.gov

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Table 3 Examples of Potential Human Factors Problems from the “Dirty Dozen”

Potential Solutions

10. Stress Be aware of how stress can affect your work.

Stop and look rationally at the problem.
Determine a rational course of action and follow it.
Take time off or at least have a short break.
Discuss it with someone.
Ask fellow workers to monitor your work.
Exercise your body.

11. Lack of Think of what may occur in the event of an accident.

awareness Check to see if your work will conflict with an existing modification or
Ask others if they can see any problem with the work done.

12. Norms Always work as per the instructions or have the instruction changed.
Be aware the “norms” don’t make it right.

8.4 The UK Human Factors Combined Action Group (UK-HFCAG) have suggested a
generic MRM syllabus which organisations may wish to adopt1. MRM training
programmes have been implemented by several airlines and many claim that such
training is extremely successful. There has been work carried out to evaluate the
success of MRM and the reader is directed in particular at research by Taylor2, which
looks at the success of MRM programmes in various US airlines.
Further Reading:
a) Sian, B., Robertson, M., Watson, J. (1998) Maintenance Resource Management
Handbook. Available from http://hfskyway.faa.gov
b) UK HFCAG (1999) People, Practices and Procedures in Aviation Engineering and
c) Human Factors Digest No. 12 (1995) Human Factors in Aircraft Maintenance and
Inspection. (ICAO Circular 253)
d) Human Factors Digest No. 3 (1991) Training of Operational Personnel in Human
Factors. (ICAO Circular 227)

1. UK-HFCAG (1999) People, Practices and Procedures in Aviation Engineering and Maintenance. Available from SRG
website: www.srg.caa.co.uk
2. Taylor, J. (1998) Evaluating the effects of Maintenance Resource Management (MRM) Interventions in Airline Safety.
Available from http://hfskyway.faa.gov

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Chapter 4 Factors Affecting Performance

The performance abilities and limitations of aircraft maintenance engineers have been
described in Chapter 2. Other factors may also impinge on the engineer, potentially
rendering him less able to carry out his work and attain the levels of safety required.
These include fitness and health, stress, time pressures, workload, fatigue and the
effects of medication, alcohol and drugs. These subjects are discussed in this

1 Fitness and Health

1.1 The job of an aircraft maintenance engineer can be physically demanding. In addition,
his work may have to be carried out in widely varying physical environments, including
cramped spaces, extremes of temperature, etc. (as discussed in the next chapter).
There are at present no defined requirements for physical or mental fitness for
engineers or maintenance staff. ICAO Annex 11 states:
“An applicant shall, before being issued with any licence or rating [for
personnel other than flight crew members], meet such requirements in
respect of age, knowledge, experience and, where appropriate, medical
fitness and skill, as specified for that licence or rating.”
1.2 In the UK, the ICAO requirements are enforced through the provision of Article 13
(paragraph 7) of the Air Navigation order (ANO)2. This states:
“The holder of an aircraft maintenance engineer’s licence shall not
exercise the privileges of such a licence if he knows or suspects that his
physical or mental condition renders him unfit to exercise such
1.3 There are two aspects to fitness and health: the disposition of the engineer prior to
taking on employment and the day-to-day well being of the engineer once employed.
1.4 Pre-employment Disposition
Some employers may require a medical upon commencement of employment. This
allows them to judge the fitness and health of an applicant (and this may also satisfy
some pension or insurance related need). There is an obvious effect upon an
engineer’s ability to perform maintenance or carry out inspections if through poor
physical fitness or health he is constrained in some way (such as his freedom of
movement, or his sight). In addition, an airworthiness authority, when considering
issuing a licence, will consider these factors and may judge the condition to be of
such significance that a licence could not be issued. This would not, however, affect
the individual’s possibility of obtaining employment in an alternative post within the
industry where fitness and health requirements are less stringent.

1. ICAO (1988) Annex 1 - Personnel Licensing. 8th edition, July 1988. Reprinted March 2000.
2. CAA (2001) CAP393: Air Navigation: The Order and the Regulations. UK Civil Aviation Authority.

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1.5 Day-to-Day Fitness and Health

1.5.1 Fitness and health can have a significant affect upon job performance (both physical
and cognitive). Day-to-day fitness and health can be reduced through illness (physical
or mental) or injury.

JAR 66.50 imposes a requirement that “certifying staff must not exercise the privileges of
their certification authorisation if they know or suspect that their physical or mental
condition renders them unfit.”

1.5.2 Responsibility falls upon the individual aircraft maintenance engineer to determine
whether he is not well enough to work on a particular day. Alternatively, his
colleagues or supervisor may persuade or advise him to absent himself until he feels
better. In fact, as the CAA’s Airworthiness Notice No. 47 (AWN47)1 points out, it is a
legal requirement for aircraft maintenance engineers to make sure they are fit for
“Fitness: In most professions there is a duty of care by the individual to
assess his or her own fitness to carry out professional duties. This has
been a legal requirement for some time for doctors, flight crew members
and air traffic controllers. Licensed aircraft maintenance engineers are
also now required by law to take a similar professional attitude. Cases of
subtle physical or mental illness may not always be apparent to the
individual but as engineers often work as a member of a team any sub-
standard performance or unusual behaviour should be quickly noticed by
colleagues or supervisors who should notify management so that
appropriate support and counselling action can be taken.”
1.5.3 Many conditions can impact on the health and fitness of an engineer and there is not
space here to offer a complete list. However, such a list would include:
• Minor physical illness (such as colds, ‘flu, etc.);
• More major physical illness (such as HIV, malaria, etc.);
• Mental illness (such as depression, etc.);
• Minor injury (such as a sprained wrist, etc.);
• Major injury (such as a broken arm, etc.);
• Ongoing deterioration in physical condition, possibly associated with the ageing
process (such as hearing loss, visual defects, obesity, heart problems, etc.);
• Affects of toxins and other foreign substances (such as carbon monoxide
poisoning, alcohol, illicit drugs, etc.).
1.5.4 This document does not attempt to give hard and fast guidelines as to what
constitutes ‘unfit for work’; this is a complex issue dependent upon the nature of the
illness or condition, its effect upon the individual, the type of work to be done,
environmental conditions, etc. Instead, it is important that the engineer is aware that
his performance, and consequently the safety of aircraft he works on, might be
affected adversely by illness or lack of fitness.
1.5.5 An engineer may consider that he is letting down his colleagues by not going to work
through illness, especially if there are ongoing manpower shortages. However, he
should remind himself that, in theory, management should generally allow for
contingency for illness. Hence the burden should not be placed upon an individual to

1. CAA (1999) CAP455: Airworthiness Notices. AWN47. UK Civil Aviation Authority.

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turn up to work when unfit if no such contingency is available. Also, if the individual
has a contagious illness (e.g. ‘flu), he may pass this on to his colleagues if he does not
absent himself from work and worsen the manpower problem in the long run. There
can be a particular problem with some contract staff due to loss of earnings or even
loss of contract if absent from work due to illness. They may be tempted to disguise
their illness, or may not wish to admit to themselves or others that they are ill. This is
of course irresponsible, as the illness may well adversely affect the contractor’s
standard of work.
1.6 Positive Measures
1.6.1 Aircraft maintenance engineers can take common sense steps to maintain their
fitness and health. These include:
• Eating regular meals and a well-balanced diet;
• Taking regular exercise (exercise sufficient to double the resting pulse rate for 20
minutes, three times a week is often recommended);
• Stopping smoking;
• Sensible alcohol intake (for men, this is no more than 3 - 4 units a day or 28 per
week, where a unit is equivalent to half a pint of beer or a glass of wine or spirit);
1.6.2 Finally, day-to-day health and fitness can be influenced by the use of medication,
alcohol and illicit drugs. These are covered later in Section 6.
Further Reading:
a) CAA (1999) CAP455: Airworthiness Notices. AWN47. UK Civil Aviation Authority.
b) Thom, T. (1999) The Air Pilot’s Manual Volume 6: Human Factors and Pilot
Performance (3rd edition). Shrewsbury: Airlife Publishing - Chapter 4 (aimed at
pilots, but generally applicable to engineers)
c) Hawkins, F.H. (1993) Human Factors in Flight (2nd edition). Aldershot: Ashgate -
Chapter 4.
d) Campbell, R. D and Bagshaw, M. (1999) Human Performance and Limitations in
Aviation (2nd edition). Oxford: Blackwell Scientific - Chapter 4.

2 Stress: Domestic and Work Related

2.1 Stress is an inescapable part of life for all of us.

Stress can be defined as any force, that when applied to a system, causes some
significant modification of its form, where forces can be physical, psychological or due to
social pressures.

Source: Penguin Dictionary of Psychology1

2.2 From a human viewpoint, stress results from the imposition of any demand or set of
demands which require us to react, adapt or behave in a particular manner in order to
cope with or satisfy them. Up to a point, such demands are stimulating and useful,
but if the demands are beyond our personal capacity to deal with them, the resulting
stress is a problem.

1. Reber, A.S. (1995) Dictionary of Psychology (2nd edition). London: Penguin.

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2.3 Causes and Symptoms

2.3.1 Stress is usually something experienced due to the presence of some form of
stressor, which might be a one-off stimulus (such as a challenging problem or a
punch on the nose), or an on-going factor (such as an extremely hot hangar or an
acrimonious divorce). From these, we get acute stress (typically intense but of short
duration) and chronic stress (frequent recurrence or of long duration) respectively.
2.3.2 Different stressors affect different people to varying extents. Stressors may be:
• Physical - such as heat, cold, noise, vibration, presence of something damaging to
health (e.g. carbon monoxide);
• Psychological - such as emotional upset (e.g. due to bereavements, domestic
problems, etc.), worries about real or imagined problems (e.g. due to financial
problems, ill health, etc.);
• Reactive - such as events occurring in everyday life (e.g. working under time
pressure, encountering unexpected situations, etc.).
2.3.3 AWN47 points out that:
“A stress problem can manifest itself by signs of irritability, forgetfulness,
sickness absence, mistakes, or alcohol or drug abuse. Management have
a duty to identify individuals who may be suffering from stress and to
minimise workplace stresses. Individual cases can be helped by
sympathetic and skilful counselling which allows a return to effective
work and licensed duties.”
2.3.4 In brief, the possible signs of stress can include:
• Physiological symptoms - such as sweating, dryness of the mouth, etc.;
• Health effects - such as nausea, headaches, sleep problems, diarrhoea, ulcers,
• Behavioural symptoms - such as restlessness, shaking, nervous laughter, taking
longer over tasks, changes to appetite, excessive drinking, etc.;
• Cognitive effects - such as poor concentration, indecision, forgetfulness, etc.;
• Subjective effects - such as anxiety, irritability, depression, moodiness,
aggression, etc.

It should be noted that individuals respond to stressful situations in very different ways.
Generally speaking though, people tend to regard situations with negative consequences
as being more stressful than when the outcome of the stress will be positive (e.g. the
difference between being made redundant from work and being present at the birth of a
son or daughter).

2.4 Domestic Stress

2.4.1 When aircraft maintenance engineers go to work, they cannot leave stresses
associated with home behind. Pre-occupation with a source of domestic stress can
play on one’s mind during the working day, distracting from the working task. Inability
to concentrate fully may impact on the engineer’s task performance and ability to pay
due attention to safety.
2.4.2 Domestic stress typically results from major life changes at home, such as marriage,
birth of a child, a son or daughter leaving home, bereavement of a close family
member or friend, marital problems, or divorce.

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2.5 Work Related Stress

2.5.1 Aircraft maintenance engineers can experience stress for two reasons at work:
because of the task or job they are undertaking at that moment, or because of the
general organisational environment. Stress can be felt when carrying out certain tasks
that are particularly challenging or difficult. This stress can be increased by lack of
guidance in this situation, or time pressures to complete the task or job (covered later
in this chapter). This type of stress can be reduced by careful management, good
training, etc.
2.5.2 Within the organisation, the social and managerial aspects of work can be stressful.
Chapter 3 discussed the impact on the individual of peer pressure, organisational
culture and management, all of which can be stressors. In the commercial world that
aircraft maintenance engineers work in, shift patterns, lack of control over own
workload, company reorganisation and job uncertainty can also be sources of stress.
2.6 Stress Management
2.6.1 Once we become aware of stress, we generally respond to it by using one of two
strategies: defence or coping.

Defence strategies involve alleviation of the symptoms (taking medication, alcohol, etc.) or
reducing the anxiety (e.g. denying to yourself that there is a problem (denial), or blaming
someone else).

2.6.2 Coping strategies involve dealing with the source of the stress rather than just the
symptoms (e.g. delegating workload, prioritising tasks, sorting out the problem, etc.).

Coping is the process whereby the individual either adjusts to the perceived demands of
the situation or changes the situation itself.

Source: Green, R.G. et al (1996)1

2.6.3 Unfortunately, it is not always possible to deal with the problem if this is outside the
control of the individual (such as during an emergency), but there are well-published
techniques for helping individuals to cope with stress2. Good stress management
techniques include:
• Relaxation techniques;
• Careful regulation of sleep and diet;
• A regime of regular physical exercise;
• Counselling - ranging from talking to a supportive friend or colleague to seeking
professional advice.
2.6.4 There is no magic formula to cure stress and anxiety, merely common sense and
practical advice.
Further Reading:
a) Campbell, R.D. and Bagshaw, M. (1999) Human Performance and Limitations in
Aviation (2nd edition). Oxford: Blackwell Scientific - Section 10.2.

1. Green, R.G.; Muir, H.; James, M.; Gradwell, D. and Green, R.L. (1996) Human Factors For Pilots (2nd edition). Aldershot:
2. Wilkinson, G. (1997) Understanding Stress. Family Doctor Publications.

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b) Ribak, J., Rayman, R.B., Froom, P. (1995) Occupational Health in Aviation:

Maintenance and Support Personnel. Academic Press - Chapter 5.
c) Stokes, A., Kite, K. (1994) Flight Stress: Stress, Fatigue and Performance in
Aviation. Aldershot: Avebury.
d) Wilkinson, G. (1997) Understanding Stress. Family Doctor Publications.

3 Time Pressure and Deadlines

3.1 There is probably no industry in the commercial environment that does not impose
some form of deadline, and consequently time pressure, on its employees. Aircraft
maintenance is no exception. It was highlighted in the previous section that one of
the potential stressors in maintenance is time pressure. This might be actual
pressure where clearly specified deadlines are imposed by an external source (e.g.
management or supervisors) and passed on to engineers, or perceived where
engineers feel that there are time pressures when carrying out tasks, even when no
definitive deadlines have been set in stone. In addition, time pressure may be self-
imposed, in which case engineers set themselves deadlines to complete work (e.g.
completing a task before a break or before the end of a shift).
3.2 Management have contractual pressures associated with ensuring an aircraft is
released to service within the time frame specified by their customers. Striving for
higher aircraft utilisation means that more maintenance must be accomplished in
fewer hours, with these hours frequently being at night. Failure to do so can impact
on flight punctuality and passenger satisfaction. Thus, aircraft maintenance engineers
have two driving forces: the deadlines handed down to them and their responsibilities
to carry out a safe job. The potential conflict between these two driving pressures can
cause problems.
3.3 The Effects of Time Pressure and Deadlines
As with stress, it is generally thought that some time pressure is stimulating and may
actually improve task performance. However, it is almost certainly true that excessive
time pressure (either actual or perceived, external or self-imposed), is likely to mean
that due care and attention when carrying out tasks diminishes and more errors will
be made. Ultimately, these errors can lead to aircraft incidents and accidents.

It is possible that perceived time pressure would appear to have been a contributory factor
in the BAC 1-11 accident described in Chapter 1. Although the aircraft was not required the
following morning for operational use, it was booked for a wash. The wash team had been
booked the previous week and an aircraft had not been ready. This would have happened
again, due to short-staffing, so the Shift Manager decided to carry out the windscreen
replacement task himself so that the aircraft would be ready in time.

Source: AAIB, 19921

1. AAIB (1992) Report on the accident to BAC 1-11, G-BJRT over Didcot, Oxfordshire on 10 June 1990. Aircraft Accident
Report 1/92.

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An extract from the NTSB report on the Aloha accident refers to time pressure as a
possible contributory factor in the accident: “The majority of Aloha's maintenance was
normally conducted only during the night. It was considered important that the airplanes
be available again for the next day's flying schedule. Such aircraft utilization tends to drive
the scheduling, and indeed, the completion of required maintenance work. Mechanics and
inspectors are forced to perform under time pressure. Further, the intense effort to keep
the airplanes flying may have been so strong that the maintenance personnel were
reluctant to keep airplanes in the hangar any longer than absolutely necessary.”

Source: NTSB, 19891

3.4 Managing Time Pressure and Deadlines
3.4.1 One potential method of managing time pressures exerted on engineers is through
regulation. For example, FAA research has highlighted the need to insulate aircraft
maintenance engineers from commercial pressures. They consider this would help to
ensure that airworthiness issues will always take precedence over commercial and
time pressures. Time pressures can make ‘corner-cutting’ a cultural norm in an
organisation. Sometimes, only an incident or accident reveals such norms (the extract
from the Aloha accident above exemplifies this).
3.4.2 Those responsible for setting deadlines and allocating tasks should consider:
• Prioritising various pieces of work that need to be done;
• The actual time available to carry out work (considering breaks, shift handovers,
• The personnel available throughout the whole job (allowing a contingency for
• The most appropriate utilisation of staff (considering an engineer’s specialisation,
and strengths and limitations);
• Availability of parts and spares.

It is important that engineering staff at all levels are not afraid to voice concerns over
inappropriate deadlines, and if necessary, cite the need to do a safe job to support this. As
highlighted in Chapter 3, within aircraft maintenance, responsibility should be spread
across all those who play a part. Thus, the aircraft maintenance engineer should not feel
that the ‘buck stops here’.

Further Reading:
a) King, D. (1998) Learning Lessons the (not quite so) Hard Way; Incidents - the route
to human factors in engineering. In: Proceedings of the 12th Symposium on
Human Factors in Aviation Maintenance.

1. NTSB (1989) Aircraft Accident Report--Aloha Airlines, Flight 243, Boeing 737-200, N73711, near Maui, Hawaii, April 28,
1988. NTSB/AAR 89/03

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4 Workload - Overload and Underload

4.1 The preceding sections on stress and time pressure have both indicated that a certain
amount of stimulation is beneficial to an aircraft maintenance engineer, but that too
much stimulation can lead to stress or over-commitment in terms of time. It is
noteworthy that too little stimulation can also be a problem.
4.2 Before going on to discuss workload, it is important to consider this optimum level of
stimulation or arousal.
4.3 Arousal
4.3.1 Arousal in its most general sense, refers to readiness of a person for performing
work. To achieve an optimum level of task performance, it is necessary to have a
certain level of stimulation or arousal. This level of stimulation or arousal varies from
person to person. There are people who are overloaded by having to do more than
one task at a time; on the other hand there are people who appear to thrive on stress,
being happy to take on more and more work or challenges. Figure 16 shows the
general relationship between arousal and task performance.


Poor Poor
Performance Performance

Level of

Under - Aroused Optimum Arousal Over - Aroused

Figure 16 Optimum arousal leads to best task performance (adapted from Thom
1. Thom, T. (1999) The Pilot’s Manual Volume 6: Human Factors and Pilot Performance (3rd edition).
Shrewsbury: Airlife Publishing.

4.3.2 At low levels of arousal, our attentional mechanisms will not be particularly active and
our performance capability will be low (complacency and boredom can result). At
the other end of the curve, performance deteriorates when arousal becomes too high.
To a certain extent, this is because we are forced to shed tasks and focus on key
information only (called narrowing of attention). Best task performance occurs
somewhere in the middle.
4.3.3 In the work place, arousal is mainly influenced by stimulation due to work tasks.
However, surrounding environmental factors such as noise may also influence the
level of arousal.

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4.4 Factors Determining Workload

4.4.1 An individual aircraft maintenance engineer can usually identify what work he has to
do quite easily. It is more difficult to assess how that work translates into workload.

The degree of stimulation exerted on an individual caused by a task is generally referred to

as workload, and can be separated into physical workload and mental workload.

4.4.2 As noted in the section on information processing in Chapter 2, humans have limited
mental capacity to deal with information. We are also limited physically, in terms of
visual acuity, strength, dexterity and so on. Thus, workload reflects the degree to
which the demands of the work we have to do eats into our mental and physical
capacities. Workload is subjective (i.e. experienced differently by different people)
and is affected by:
• The nature of the task, such as the:
• physical demands it requires (e.g. strength required, etc.);
• mental demands it requires (e.g. complexity of decisions to be made, etc.).
• The circumstances under which the task is performed, such as the:
• standard of performance required (i.e. degree of accuracy);
• time available to accomplish the task (and thus the speed at which the task
must be carried out);
• requirement to carry out the task at the same time as doing something else;
• perceived control of the task (i.e. is it imposed by others or under your
control, etc.);
• environmental factors existing at time (e.g. extremes of temperature, etc.).
• The person and his state, such as his:
• skills (both physical and mental);
• his experience (particularly familiarity with the task in question);
• his current health and fitness levels;
• his emotional state (e.g. stress level, mood, etc.).
4.4.3 As the workload of the engineer may vary, he may experience periods of overload and
underload. This is a particular feature of some areas of the industry such as line
4.5 Overload
Overload occurs at very high levels of workload (when the engineer becomes over
aroused). As highlighted previously, performance deteriorates when arousal becomes
too high and we are forced to shed tasks and focus on key information. Error rates
may also increase. Overload can occur for a wide range of reasons based on the
factors highlighted above. It may happen suddenly (e.g. if asked to remember one
further piece of information whilst already trying to remember a large amount of data),
or gradually. Although JAR145 states that “The JAR145 approved maintenance
organisation must employ sufficient personnel to plan, perform, supervise and
inspect the work in accordance with the approval”1, and “the JAR145 organisation
should have a production man hours plan showing that it has sufficient man hours for

1. JAR145.30 (b), July 1998

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the work that is intended to be carried out”1, this does not prevent individuals from
becoming overloaded. As noted earlier in this section, it can be difficult to determine
how work translates into workload, both for the individual concerned, and for those
allocating tasks.
4.6 Underload
Underload occurs at low levels of workload (when the engineer becomes under
aroused). It can be just as problematic to an engineer as overload, as it too causes a
deterioration in performance and an increase in errors, such as missed information.
Underload can result from a task an engineer finds boring, very easy, or indeed a lack
of tasks. The nature of the aircraft maintenance industry means that available work
fluctuates, depending on time of day, maintenance schedules, and so forth. Hence,
unless stimulating ‘housekeeping’ tasks can be found, underload can be difficult to
avoid at times.
4.7 Workload Management
4.7.1 Unfortunately, in a commercial environment, it is seldom possible to make large
amendments to maintenance schedules, nor eliminate time pressures. The essence
of workload management in aircraft maintenance should include:
• ensuring that staff have the skills needed to do the tasks they have been asked to
do and the proficiency and experience to do the tasks within the timescales they
have been asked to work within;
• making sure that staff have the tools and spares they need to do the tasks;
• allocating tasks to teams or individual engineers that are accomplishable (without
cutting corners) in the time available;
• providing human factors training to those responsible for planning so that the
performance and limitations of their staff are taken into account;
• encouraging individual engineers, supervisors and managers to recognise when an
overload situation is building up.
4.7.2 If an overload situation is developing, methods to help relieve this include:
• seeking a simpler method of carrying out the work (that is just as effective and still
• delegating certain activities to others to avoid an individual engineer becoming
• securing further time in order to carry out the work safely;
• postponing, delaying tasks/deadlines and refusing additional work.
4.7.3 Thus, although workload varies in aircraft maintenance engineering, the workload of
engineers can be moderated. Much of this can be done by careful forward planning
of tasks, manpower, spares, tools and training of staff.
Further Reading:
a) JAR 145.30 (b), & JAR145 AMC 145.30 (b). July 1998
b) Thoms, T. (1999) The Air Pilot’s Manual Volume 6: Human Factors and Pilot
Performance (3rd edition). Shrewsbury: Airlife Publishing - Chapter 6.
c) Ribak, J., Rayman, R.B., Froom, P. (1995) Occupational Health in Aviation:
Maintenance and Support Personnel - Chapter 5

1. JAR145.30 (b) AMC 145.30 (b) July 1998

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5 Sleep, Fatigue and Shift Work

5.1 What Is Sleep?

5.1.1 Man, like all living creatures has to have sleep. Despite a great deal of research, the
purpose of sleep is not fully understood.

Sleep is a natural state of reduced consciousness involving changes in body and brain
physiology which is necessary to man to restore and replenish the body and brain.

5.1.2 Sleep can be resisted for a short time, but various parts of the brain ensure that
sooner or later, sleep occurs. When it does, it is characterised by five stages of sleep:
• Stage 1: This is a transitional phase between waking and sleeping. The heart rate
slows and muscles relax. It is easy to wake someone up.
• Stage 2: This is a deeper level of sleep, but it is still fairly easy to wake someone.
• Stage 3: Sleep is even deeper and the sleeper is now quite unresponsive to
external stimuli and so is difficult to wake. Heart rate, blood pressure and body
temperature continue to drop.
• Stage 4: This is the deepest stage of sleep and it is very difficult to wake someone
• Rapid Eye Movement or REM Sleep: Even though this stage is characterised by
brain activity similar to a person who is awake, the person is even more difficult to
awaken than stage 4. It is therefore also known as paradoxical sleep. Muscles
become totally relaxed and the eyes rapidly dart back and forth under the eyelids.
It is thought that dreaming occurs during REM sleep.
5.1.3 Stages 1 to 4 are collectively known as non-REM (NREM) sleep. Stages 2-4 are
categorised as slow-wave sleep and appear to relate to body restoration, whereas
REM sleep seems to aid the strengthening and organisation of memories. Sleep
deprivation experiments suggest that if a person is deprived of stage 1-4 sleep or
REM sleep he will show rebound effects. This means that in subsequent sleep, he
will make up the deficit in that particular type of sleep. This shows the importance of
both types of sleep.
5.1.4 As can be seen from Figure 17, sleep occurs in cycles. Typically, the first REM sleep
will occur about 90 minutes after the onset of sleep. The cycle of stage 1 to 4 sleep
and REM sleep repeats during the night about every 90 minutes. Most deep sleep
occurs earlier in the night and REM sleep becomes greater as the night goes on.

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Figure 17 Typical cycle of stage 1-4 (NREM) sleep and REM sleep in the course of
a night. Source: Gross, 19961

5.2 Circadian Rhythms

5.2.1 Apart from the alternation between wakefulness and sleep, man has other internal
cycles, such as body temperature and hunger/eating. These are known as circadian
rhythms as they are related to the length of the day.

Circadian rhythms are physiological and behavioural functions and processes in the body
that have a regular cycle of approximately a day (actually about 25 hours in man).

5.2.2 Although, circadian rhythms are controlled by the brain, they are influenced and
synchronised by external (environmental) factors such as light.

An example of disrupting circadian rhythms would be taking a flight that crosses time
zones. This will interfere with the normal synchronisation with the light and dark (day/
night). This throws out the natural link between daylight and the body’s internal clock,
causing jet lag, resulting in sleepiness during the day, etc. Eventually however, the
circadian rhythm readjusts to the revised environmental cues.

5.2.3 Figure 18 shows the circadian rhythm for body temperature. This pattern is very
robust, meaning that even if the normal pattern of wakefulness and sleep is disrupted
(by shift work for example), the temperature cycle remains unchanged. Hence, it can
be seen that if you are awake at 4-6 o’clock in the morning, your body temperature is
in a trough and it is at this time that is hardest to stay awake. Research has shown
that this drop in body temperature appears to be linked to a drop in alertness and
performance in man.

1. Gross, R. (1996) Psychology: The Science of Mind and Behaviour (3rd edition). London: Hodder and Stoughton.

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Figure 18 The Circadian Rhythm for Internal Body Temperature

Although there are many contributory factors, it is noteworthy that a number of major
incidents and accidents involving human error have either occurred or were initiated in the
pre-dawn hours, when body temperature and performance capability are both at their
lowest. These include Three Mile Island, Chernobyl, and Bhopal, as well as the BAC1-11,
A320, and B737 incidents summarised in Chapter 1.

5.2.4 The engineer’s performance at this ‘low point’ will be improved if he is well rested,
feeling well, highly motivated and well practised in the skills being used at that point.
5.3 Fatigue
5.3.1 Fatigue can be either physiological or subjective. Physiological fatigue reflects the
body’s need for replenishment and restoration. It is tied in with factors such as recent
physical activity, current health, consumption of alcohol, and with circadian rhythms.
It can only be satisfied by rest and eventually, a period of sleep. Subjective fatigue
is an individual’s perception of how sleepy they feel. This is not only affected by when
they last slept and how good the sleep was but other factors, such as degree of
5.3.2 Fatigue is typically caused by delayed sleep, sleep loss, desynchronisation of normal
circadian rhythms and concentrated periods of physical or mental stress or exertion.
In the workplace, working long hours, working during normal sleep hours and working
on rotating shift schedules all produce fatigue to some extent.

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5.3.3 Symptoms of fatigue (in no particular order) may include:

• diminished perception (vision, hearing, etc.) and a general lack of awareness;
• diminished motor skills and slow reactions;
• problems with short-term memory;
• channelled concentration - fixation on a single possibly unimportant issue, to the
neglect of others and failing to maintain an overview;
• being easily distracted by unimportant matters;
• poor judgement and decision making leading to increased mistakes;
• abnormal moods - erratic changes in mood, depressed, periodically elated and
• diminished standards of own work.
5.3.4 AWN47 highlights the potential for fatigue in aircraft maintenance engineering:
“Tiredness and fatigue can adversely affect performance. Excessive
hours of duty and shift working, particularly with multiple shift periods or
additional overtime, can lead to problems. Individuals should be fully
aware of the dangers of impaired performance due to these factors and
of their personal responsibilities.”
5.4 Shift Work
Most aircraft movements occur between 6 a.m. and 10 p.m. to fit in with the
requirements of passengers. Aircraft maintenance engineers are required whenever
aircraft are on the ground, such as during turn arounds. However, this scheduling
means that aircraft are often available for more significant maintenance during the
night. Thus, aircraft maintenance engineering is clearly a 24 hour business and it is
inevitable that, to fulfil commercial obligations, aircraft maintenance engineers usually
work shifts. Some engineers permanently work the same shift, but the majority cycle
through different shifts. These typically comprise either an ‘early shift’, a ‘late shift’
and a ‘night shift’, or a ‘day shift’ and a ‘night shift’ depending on the maintenance
5.4.1 Advantages and Disadvantages of Shift Work
There are pros and cons to working shifts. Some people welcome the variety of
working different times associated with regular shift work patterns. Advantages may
include more days off and avoiding peak traffic times when travelling to work. The
disadvantages of shift working are mainly associated with:
• working ‘unsociable hours’, meaning that time available with friends, family, etc.
will be disrupted;
• working when human performance is known to be poorer (i.e. between 4 a.m and
6 a.m.);
• problems associated with general desynchronisation and disturbance of the body’s
various rhythms (principally sleeping patterns).
5.4.2 Working At Night
Shift work means that engineers will usually have to work at night, either permanently
or as part of a rolling shift pattern. As discussed earlier in this chapter, this introduces
the inherent possibility of increased human errors. Working nights can also lead to
problems sleeping during the day, due to the interference of daylight and

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environmental noise. Blackout curtains and use of ear plugs can help, as well as
avoidance of caffeine before sleep.

In the B737 double engine oil loss incident, the error occurred during the night shift. The
accident investigation report commented that: “It is under these circumstances that the
fragility of the self monitoring system is most exposed because the safety system can be
jeopardised by poor judgement on the part of one person and it is also the time at which
people are most likely to suffer impaired judgement”.

5.4.3 Rolling Shift Patterns

When an engineer works rolling shifts and changes from one shift to another (e.g.
‘day shift’ to ‘night shift’), the body's internal clock is not immediately reset. It
continues on its old wake-sleep cycle for several days, even though it is no longer
possible for the person to sleep when the body thinks it is appropriate, and is only
gradually resynchronised. However, by this time, the engineer may have moved onto

the next shift. Generally, it is now accepted that shift rotation should be to later shifts

(i.e. early shift late shift night shift or day shift night shift) instead of rotation
towards earlier shifts (night shift late shift early shift).
5.4.4 Continuity of Tasks and Shift Handovers
Many maintenance tasks often span more than one shift, requiring tasks to be passed
from one shift to the next. The outgoing personnel are at the end of anything up to a
twelve hour shift and are consequently tired and eager to go home. Therefore, shift
handover is potentially an area where human errors can occur. Whilst longer shifts
may result in greater fatigue, the disadvantages may be offset by the fact that fewer
shift changeovers are required (i.e. only 2 handovers with 2 twelve hour shifts, as
opposed to 3 handovers with 3 eight hour shifts). Shift handover is discussed further
in Chapter 7 when looking at ‘work logging and recording’.
5.5 Sleep, Fatigue, Shift Work and the Aircraft Maintenance Engineer
5.5.1 Most individuals need approximately 8 hours sleep in a 24 hour period, although this
varies between individuals, some needing more and some happy with less than this
to be fully refreshed. They can usually perform adequately with less that this for a few
days, building up a temporary sleep ‘deficit’. However, any sleep deficit will need to
be made up, otherwise performance will start to suffer.

A good rule of thumb is that one hour of high-quality sleep is good for two hours of activity.

5.5.2 As previously noted, fatigue is best tackled by ensuring adequate rest and good
quality sleep are obtained. The use of blackout curtains if having to sleep during
daylight has already been mentioned. It is also best not to eat a large meal shortly
before trying to sleep, but on the other hand, the engineer should avoid going to bed
hungry. As fatigue is also influenced by illness, alcohol, etc., it is very important to get
more sleep if feeling a little unwell and drink only in moderation between duties
(discussed further in the next section). Taking over-the-counter drugs to help sleep
should only be used as a last resort.
5.5.3 When rotating shifts are worked, it is important that the engineer is disciplined with
his eating and sleeping times. Moreover, out of work activities have to be carefully
planned. For example, it is obvious that an individual who has been out night-clubbing
until the early hours of the morning will not be adequately rested if rostered on an
early shift.

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5.5.4 Shift working patterns encountered by aircraft maintenance engineers may include
three or four days off after the last night shift. It can be tempting to work additional
hours, taking voluntary overtime, or another job, in one or more of these days off. This
is especially the case when first starting a career in aircraft maintenance engineering
when financial pressures may be higher. Engineers should be aware that their
vulnerability to error is likely to be increased if they are tired or fatigued, and they
should try to ensure that any extra hours worked are kept within reason.

It is always sensible to monitor ones performance, especially when working additional

hours. Performance decrements can be gradual, and first signs of chronic fatigue may be
moodiness, headaches or finding that familiar tasks (such as programming the video
recorder) seem more complicated than usual.

5.5.5 Finally, it is worth noting that, although most engineers adapt to shift working, it
becomes harder to work rotating shifts as one gets older.
Further Reading:
a) Thom, T. (1999) The Air Pilot’s Manual Volume 6: Human Factors and Pilot
Performance (3rd edition). Shrewsbury: Airlife Publishing - Chapter 5.
b) Campbell, R.D. and Bagshaw, M. (1999) Human Performance and Limitations in
Aviation (2nd edition). Oxford: Blackwell Scientific - Section 10.3.
c) Maddox, M. Ed. (1998) Human Factors Guide for Aviation Maintenance 3.0.
Washington DC: Federal Aviation Administration/Office of Aviation Medicine -
Chapter 4. Available from http://hfskyway.faa.gov
d) Morgan, D. (1996) Sleep Secrets for shift workers and people with off-beat
schedules. Whole Person Associates.
e) Ribak, J., Rayman, R.B., Froom, P. (1995) Occupational Health in Aviation:
Maintenance and Support personnel - Chapter 5.

6 Alcohol, Medication and Drug Abuse

6.1 It should come as no surprise to the aircraft maintenance engineer that his
performance will be affected by alcohol, medication or illicit drugs. Under both UK and
JAA legislation it is an offence for safety critical personnel to carry out their duties
whilst under the influence of alcohol or drugs. Article 13 (paragraph 8) of the UK ANO,
“The holder of an aircraft maintenance engineer’s licence shall not, when
exercising the privileges of such a licence, be under the influence of drink
or a drug to such an extent as to impair his capacity to exercise such
6.2 The current law which does not prescribe a blood/alcohol limit, is soon to change.
There will be new legislation permitting police to test for drink or drugs where there
is reasonable cause, and the introduction of a blood/alcohol limit of 20 milligrams of
alcohol per 100 millilitres of blood for anyone performing a safety critical role in UK
civil aviation (which includes aircraft maintenance engineers).

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6.3 Alcohol
6.3.1 Alcohol acts as a depressant on the central nervous system, dulling the senses and
increasing mental and physical reaction times. It is known that even a small amount
of alcohol leads to a decline in an individual’s performance and may cause his
judgement (i.e. ability to gauge his performance) to be hindered.
6.3.2 Alcohol is removed from the blood at a fixed rate and this cannot be speeded up in
any way (e.g. by drinking strong coffee). In fact, sleeping after drinking alcohol can
slow down the removal process, as the body’s metabolic systems are slower.
6.3.3 AWN47 provides the following advice concerning alcohol:
“Alcohol has similar effects to tranquillisers and sleeping tablets and may
remain circulating in the blood for a considerable time, especially if taken
with food. It may be borne in mind that a person may not be fit to go on
duty even 8 hours after drinking large amounts of alcohol. Individuals
should therefore anticipate such effects upon their next duty period.
Special note should be taken of the fact that combinations of alcohol and
sleeping tablets, or anti-histamines, can form a highly dangerous and even
lethal combination.”

As a general rule, aircraft maintenance engineers should not work for at least eight hours
after drinking even small quantities of alcohol and increase this time if more has been

6.3.4 The affects of alcohol can be made considerably worse if the individual is fatigued, ill
or using medication.
6.4 Medication
6.4.1 Any medication, no matter how common, can possibly have direct effects or side
effects that may impair an engineer’s performance in the workplace.

Medication can be regarded as any over-the-counter or prescribed drug used for

therapeutic purposes.

6.4.2 There is a risk that these effects can be amplified if an individual has a particular
sensitivity to the medication or one of its ingredients. Hence, an aircraft maintenance
engineer should be particularly careful when taking a medicine for the first time, and
should ask his doctor whether any prescribed drug will affect his work performance.
It is also wise with any medication to take the first dose at least 24 hours before any
duty to ensure that it does not have any adverse effects.

Medication is usually taken to relieve symptoms of an illness. Even if the drugs taken do
not affect the engineer’s performance, he should still ask himself whether the illness has
made him temporarily unfit for work.

6.4.3 Various publications, and especially AWN47 give advice relevant to the aircraft
maintenance engineer on some of the more common medications. This information
is summarised below, however the engineer must use this with caution and should
seek further clarification from a pharmacist, doctor or their company occupational
health advisor if at all unsure of the impact on work performance.
• Analgesics are used for pain relief and to counter the symptoms of colds and ‘flu.
In the UK, paracetamol, aspirin and ibuprofen are the most common, and are

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generally considered safe if used as directed. They can be taken alone but are
often used as an ingredient of a ‘cold relief’ medicine. It is always worth bearing in
mind that the pain or discomfort that you are attempting to treat with an analgesic
(e.g. headache, sore throat, etc.) may be the symptom of some underlying illness
that needs proper medical attention.
• Antibiotics (such as Penicillin and the various mycins and cyclines) may have short
term or delayed effects which affect work performance. Their use indicates that a
fairly severe infection may well be present and apart from the effects of these
substances themselves, the side-effects of the infection will almost always render
an individual unfit for work.
• Anti-histamines are used widely in ‘cold cures’ and in the treatment of allergies
(e.g. hayfever). Most of this group of medicines tend to make the user feel drowsy,
meaning that the use of medicines containing anti-histamines is likely to be
unacceptable when working as an aircraft maintenance engineer.
• Cough suppressants are generally safe in normal use, but if an over-the-counter
product contains anti-histamine, decongestant, etc., the engineer should exercise
caution about its use when working.
• Decongestants (i.e. treatments for nasal congestion) may contain chemicals such
as pseudo-ephedrine hydrochloride (e.g. ‘Sudafed’) and phenylphrine. Side-effects
reported, are anxiety, tremor, rapid pulse and headache. AWN47 forbids the use
of medications containing this ingredient to aircraft maintenance engineers when
working, as the effects compromise skilled performance.
• ‘Pep’ pills are used to maintain wakefulness. They often contain caffeine,
dexedrine or benzedrine. Their use is often habit forming. Over-dosage may cause
headaches, dizziness and mental disturbances. AWN47 states that “the use of
‘pep’ pills whilst working cannot be permitted. If coffee is insufficient, you are not
fit for work.”
• Sleeping tablets (often anti-histamine based) tend to slow reaction times and
generally dull the senses. The duration of effect is variable from person to person.
Individuals should obtain expert medical advice before taking them.
6.4.4 Melatonin (a natural hormone) deserves a special mention. Although not available
without a prescription in the UK, it is classed as a food supplement in the USA (and is
readily available in health food shops). It has been claimed to be effective as a sleep
aid, and to help promote the resynchronisation of disturbed circadian rhythms. Its
effectiveness and safety are still yet to be proven and current best advice is to avoid
this product.

If the aircraft maintenance engineer has any doubts about the suitability of working whilst
taking medication, he must seek appropriate professional advice.

6.5 Drugs
6.5.1 Illicit drugs such as ecstasy, cocaine and heroin all affect the central nervous system
and impair mental function. They are known to have significant effects upon
performance and have no place within the aviation maintenance environment. Of
course, their possession and use are also illegal in the UK.
6.5.2 Smoking cannabis can subtly impair performance for up to 24 hours. In particular, it
affects the ability to concentrate, retain information and make reasoned judgements,
especially on difficult tasks.

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Further Reading:
a) CAA (1999) CAP455: Airworthiness Notices. AWN47. UK Civil Aviation Authority.
b) Transport Canada (1993) Shift Wise: a Shiftworker’s Guide to Good Health.
Publication number TP11658E.
c) Maddox, M.E. (Ed.) (1998) Human Factors Guide for Aviation Maintenance 3.0.
Washington DC: Federal Aviation Administration/Office of Aviation Medicine.
Available from http://hfskyway.faa.gov

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Chapter 5 Physical Environment

The aircraft maintenance engineer can expect to work in a variety of different

environments, from ‘line’ (generally outside the hangar) to ‘base’ (usually inside a
hangar or workshop), in all types of weather and climatic conditions, day and night.
This depends largely on the company he works for, and the function he fulfils in the
company. Both physical environments have their own specific features or factors that
may impinge on human performance. This chapter considers the impact of noise,
fumes, illumination, climate and temperature, motion and vibration, as well as the
requirement to work in confined spaces and issues associated with the general
working environment.

1 Noise

1.1 The impact of noise on human performance has already been discussed in Chapter 2,
Section 3 when examining ‘hearing’. To recap, noise in the workplace can have both
short-term and long-term negative effects: it can be annoying, can interfere with
verbal communication and mask warnings, and it can damage workers’ hearing
(either temporarily or permanently). It was noted that the ear is sensitive to sounds
between certain frequencies (20 HZ to 20 KHz) and that intensity of sound is
measured in decibels (dB), where exposure in excess of 115 dB without ear
protection even for a short duration is not recommended. This equates to standing
within a few hundred metres of a moving jet aircraft.

Noise can be thought of as any unwanted sound, especially if it is loud, unpleasant and

1.2 General background noise can be ‘filtered out’ by the brain through focused
attention (as noted in Chapter 2, Section 3). Otherwise, for more problematic noise,
some form of hearing protection (e.g. ear plugs and ear muffs) is commonly used
by aircraft maintenance engineers, both on the line and in the hangar, to help the
engineer to concentrate.
1.3 The noise environment in which the aircraft maintenance engineer works can vary
considerably. For instance, the airport ramp or apron area is clearly noisy, due to
running aircraft engines or auxiliary power units (APUs), moving vehicles and so on. It
is not unusual for this to exceed 85 dB - 90 dB which can cause hearing damage if the
time of exposure is prolonged. The hangar area can also be noisy, usually due to the
use of various tools during aircraft maintenance. Short periods of intense noise are
not uncommon here and can cause temporary hearing loss. Engineers may move to
and from these noisy areas into the relative quiet of rest rooms, aircraft cabins, stores
and offices.

It is very important that aircraft maintenance engineers remain aware of the extent of the
noise around them. It is likely that some form of hearing protection should be carried with
them at all times and, as a rule of thumb, used when remaining in an area where normal
speech cannot be heard clearly at 2 metres.

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1.4 In their day-to-day work, aircraft maintenance engineers will often need to discuss
matters relating to a task with colleagues and also, at the end of a shift, handover to
an incoming engineer. Clearly, in both cases it is important that noise does not impair
their ability to communicate, as this could obviously have a bearing on the successful
completion of the task (i.e. safety). Common sense dictates that important matters
are discussed away from noisy areas.
Further Reading:
a) JAR145.25(c) and JAR145 AMC145.25 (c)
b) Maddox M.E., (Ed.) (1998) Human Factors Guide for Aviation Maintenance 3.0.
Washington DC: Federal Aviation Administration/Office of Aviation Medicine -
Chapter 5. Available from http://hfskyway.faa.gov
c) Sanders, M.S., McCormick, E.J. (1993) Human Factors in Engineering and Design.
New York: McGraw-Hill - Chapter 18.

2 Fumes

2.1 By its nature, the maintenance of aircraft involves working with a variety of fluids and
chemical substances. For instance, engineers may come across various lubricants
(oils and greases), hydraulic fluids, paints, cleaning compounds and solder. They will
also be exposed to aircraft fuel and exhaust. In fact, there is every possibility that an
engineer could be exposed to a number of these at any one time in the workplace.
Each substance gives off some form of vapour or fumes which can be inhaled by the
aircraft maintenance engineer. Some fumes will be obvious as a result of their odour,
whereas others have no smell to indicate their presence. Some substances will be
benign most of the time, but may, in certain circumstances, produce fumes (e.g.
overheated grease or oils, smouldering insulation).
2.2 Fumes can cause problems for engineers mainly as a result of inhalation, but they can
also cause other problems, such as eye irritation. The problem may be exacerbated
in aircraft maintenance engineering by the confined spaces in which work must
sometimes be carried out (e.g. fuel tanks). Here the fumes cannot dissipate easily and
it may be appropriate to use breathing apparatus.
2.3 It may not always be practical to eradicate fumes from the aircraft maintenance
engineer’s work place, but where possible, steps should be taken to minimise them.
It is also common sense that if noxious fumes are detected, an engineer should
immediately inform his colleagues and supervisor so that the area can be evacuated
and suitable steps taken to investigate the source and remove them.

Apart from noxious fumes that have serious health implications and must be avoided,
working in the presence of fumes can affect an engineer’s performance, as he may rush a
job in order to escape them. If the fumes are likely to have this effect, the engineer should
increase the ventilation locally or use breathing apparatus to dissipate the fumes.

Further Reading:
a) Ribak, J., Rayman, R.B., Froom, P. (1995) Occupational Health in Aviation:
Maintenance and Support personnel - Chapter 3.
b) Wenner, C.L. and Drury, C.G. (1996) A Unified Incident Reporting System For
Maintenance Facilities. In: Phase VI Progress Report. Available from http://

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3 Illumination

3.1 In order that aircraft maintenance engineers are able to carry out their work safely and
efficiently, it is imperative that their work be conducted under proper lighting
conditions. It was noted in Chapter 2, Section 2 that the cones in the retina of the eye
require good light to resolve fine detail. Furthermore, colour vision requires adequate
light to stimulate the cones. Inappropriate or insufficient lighting can lead to mistakes
in work tasks or can increase the time required to do the work.

Illumination refers to the lighting both within the general working environment and also in
the locality of the engineer and the task he is carrying out. It can be defined as the amount
of light striking a surface.

3.2 When working outside during daylight, the engineer may have sufficient natural light
to see well by. It is possible however that he may be in shadow (possibly caused by
the aircraft) or a building. Similarly, cramped equipment compartments will not be
illuminated by ambient hangar lighting. In these cases, additional local artificial
lighting is usually required (known as task lighting). At night, aerodromes may
appear to be awash with floodlights and other aerodrome lighting, but these are
unlikely to provide sufficient illumination for an engineer to be able to see what he is
doing when working on an aircraft. These lights are not designed and placed for this
purpose. Again, additional local artificial lighting is needed, which may be nothing
more than a good torch (i.e. one which does not have a dark area in the centre of the
beam). However, the drawback of a torch, is that it leaves the engineer with only one
hand available with which to work. A light mounted on a headband gets round this
Please refer to Photograph C in Appendix A.

A torch can be very useful to the engineer, but Murphy’s Law dictates that the torch
batteries will run down when the engineer is across the airfield from the stores. It is much
wiser to carry a spare set of batteries than ‘take a chance’ by attempting a job without
enough light.

3.3 Within the hangar, general area lighting tends to be some distance from the aircraft
on which an engineer might work, as it is usually attached to the very high ceiling of
these buildings. This makes these lights hard to reach, meaning that they tend to get
dusty, making them less effective and, in addition, failed bulbs tend not to be replaced
as soon as they go out. In general, area lighting in hangars is unlikely to be as bright
as natural daylight and, as a consequence, local task lighting is often needed,
especially for work of a precise nature (particularly visual inspection tasks).

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An extract from the NTSB report on the Northwest Airlines accident at Tokyo, 1994,
illustrates these points:

“The Safety Board believes that the "OK to Close" inspector was hindered considerably by
the environment of the pylon area. He indicated, for example, that the combination of
location of the scaffolding (at a level just below the underside of the wing that forced him
into unusual and uncomfortable physical positions) and inadequate lighting from the base
of the scaffolding up toward the pylon, hampered his inspection efforts. Moreover, the
underside of the pylon was illuminated by portable fluorescent lights that had been placed
along the floor of the scaffolding. These lights had previously been used in areas where
airplanes were painted, and, as a result, had been covered with the residue of numerous
paint applications that diminished their brightness. These factors combined to cause the
inspector to view the fuse pin retainers by holding onto the airplane structure with one
hand, leaning under the bat wing doors at an angle of at least 30°, holding a flashlight with
the other hand pointing to the area, and moving his head awkwardly to face up into the
pylon area.”

Source: NTSB (1994)1

3.4 It is also important that illumination is available where the engineer needs it (i.e. both
in the hangar and one the line). Any supplemental task lighting must be adequate in
terms of its brightness for the task at hand, which is best judged by the engineer.
When using task lighting, it should be placed close to the work being done, but should
not be in the engineer’s line of sight as this will result in direct glare. It must also be
arranged so that it does not reflect off surfaces near where the engineer is working
causing indirect or reflected glare. Glare of either kind will be a distraction from the
task and may cause mistakes.
Please refer to Photograph D in Appendix A.
3.5 Poor ambient illumination of work areas has been identified as a significant deficiency
during the investigation of certain engineering incidents. It is equally important that
lighting in ancillary areas, such as offices and stores, is good.

The AAIB report for the BAC 1-11 accident says of the unmanned stores area: “The
ambient illumination in this area was poor and the Shift Maintenance Manager had to
interpose himself between the carousel and the light source to gain access to the relevant
carousel drawers. He did not use the drawer labels, even though he now knew the part
number of the removed bolt, but identified what he thought were identical bolts by placing
the bolts together and comparing them.” He also failed to make use of his spectacles.

3.6 Relying on touch when lighting is poor is no substitute for actually being able to see
what you are doing. If necessary, tools such as mirrors and borescopes may be
needed to help the engineer see into remote areas.

1. NTSB (1994) Special Investigation Report 94/02. Northwest Airlines, B747, N637US, New Tokyo International Airport,
Narita, Japan.

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Further Reading:
a) Parker, J. (1991) The Work Environment in Aviation Maintenance. In: Proceedings
of the Fifth Meeting on Human Factors Issues in Aircraft Maintenance and
Inspection. Available from http://hfskyway.faa.gov
b) Maddox, M.E. (Ed.) (1998) Human Factors Guide for Aviation Maintenance 3.0.
Washington DC: Federal Aviation Administration/Office of Aviation Medicine -
Chapter 5. Available from http://hfskyway.faa.gov
c) Sanders, M.S., McCormick, E.J. (1993) Human Factors in Engineering and Design.
New York: McGraw-Hill - Chapter 16.

4 Climate and Temperature

4.1 Humans can work within quite a wide range of temperatures and climatic conditions,
but performance is adversely affected at extremes of these. Thus, as can be seen in
Figure 19, when it is either too cold and/or wet or too hot and/or humid, performance
4.2 As has been noted throughout this document, aircraft maintenance engineers
routinely work both within the hangar and outside. Clearly, exposure to the widest
range of temperature and climate is likely to be encountered outdoors. Here, an
engineer may have to work in direct summer sun, strong winds, heavy rain, high
humidity, or in the depths of winter. Although hangars must exclude inclement
weather, they can be cold and draughty, especially if the hangar doors have to remain
4.3 JAR AMC 145.25 (c)1 states: “Hangars used to house aircraft together with office
accommodation should be such as to ensure the working environment permits
personnel to carry out work tasks in an effective manner. Temperatures should be
maintained such that personnel can carry out required tasks without undue


Poor Poor
Performance Performance

Temperature /

Cold / wet Warm / dry Hot / humid

Figure 19 The relationship between climate, temperature and performance.

1. JAR AMC 145.25(c) 10 July 1998.

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4.4 Engineers cannot be expected to maintain the rigorous standards expected in their
profession in all environmental conditions. JAR 145 Acceptable Means of Compliance
(AMC) 145.25(c) requires that environmental conditions be adequate for work to be
carried out, stating:
“The working environment for line maintenance should be such that the
particular maintenance or inspection task can be carried out without
undue distraction. It therefore follows that where the working
environment deteriorates to an unacceptable level in respect of
temperature, moisture, hail, ice, snow, wind, light, dust/other airborne
contamination, the particular maintenance or inspection tasks should be
suspended until satisfactory conditions are re-established”
4.5 Unfortunately, in reality, pressure to turn aircraft round rapidly means that some
maintenance tasks are not put off until the conditions are more conducive to work.

There was an instance in Scotland, where work on an aircraft was only suspended when it
became so cold that the lubricants being used actually froze.

4.6 Environmental conditions can affect physical performance. For example, cold
conditions make numb fingers, reducing the engineer’s ability to carry out fiddly
repairs, and working in strong winds can be distracting, especially if having to work at
height (e.g. on staging). Extreme environmental conditions may also be fatiguing,
both physically and mentally.
4.7 There are no simple solutions to the effects of temperature and climate on the
engineer. For example, an aircraft being turned around on the apron cannot usually be
moved into the hangar so that the engineer avoids the worst of the weather. In the
cold, gloves can be worn, but obviously the gloves themselves may interfere with fine
motor skills. In the direct heat of the sun or driving rain, it is usually impossible to set
up a temporary shelter when working outside.
Further Reading:
a) Sanders, M.S., McCormick, E.J. (1993) Human Factors in Engineering and Design.
New York: McGraw-Hill - Chapter 5
b) Maddox, M.E. (Ed.) (1998) Human Factors Guide for Aviation Maintenance 3.0
Washington DC: Federal Aviation Administration/Office of Aviation Medicine -
Chapter 3. Available from http://hfskyway.faa.gov

5 Motion and Vibration

5.1 Aircraft maintenance engineers often make use of staging and mobile access
platforms to reach various parts of an aircraft. As these get higher, they tend to
become less stable. For example when working at height on a scissors platform or
‘cherry picker’, applying force to a bolt being fixed to the aircraft may cause the
platform to move away from the aircraft. The extent to which this occurs does not just
depend on the height of the platform, but its design and serviceability. Any sensation
of unsteadiness may distract an engineer, as he may concentrate more on keeping
his balance than the task. Furthermore, it is vitally important that engineers use
mobile access platforms properly in order to avoid serious injury.
Please refer to Photograph E in Appendix A.

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5.2 Vibration in aircraft maintenance engineering is usually associated with the use of
rotating or percussive tools and ancillary equipment, such as generators. Low
frequency noise, such as that associated with aircraft engines, can also cause
vibration. Vibration between 0.5 Hz to 20 Hz is most problematic, as the human body
absorbs most of the vibratory energy in this range. The range between 50-150 Hz is
most troublesome for the hand and is associated with Vibratory-induced White
Finger Syndrome (VWF). Pneumatic tools can produce troublesome vibrations in
this range and frequent use can lead to reduced local blood flow and pain associated
with VWF. Vibration can be annoying, possibly disrupting an engineer’s concentration.
Further Reading:
a) DeHart, R.L. (1991) Physical Stressors In The Workplace. In: Proceedings of the
Fifth Meeting on Human Factors Issues in Aircraft Maintenance and Inspection.
Available from http://hfskyway.faa.gov

6 Confined Spaces

Chapter 2, Section 5 highlighted the possibility of claustrophobia being a problem in

aircraft maintenance engineering. Working in any confined space, especially with
limited means of entry or exit (e.g. fuel tanks) needs to be managed carefully. As
noted previously, engineers should ideally work with a colleague who would assist
their ingress into and egress out of the confined space. Good illumination and
ventilation within the confined space will reduce any feelings of discomfort. In
addition, appropriate safety equipment, such as breathing apparatus or lines must be
used when required.

7 Working Environment

7.1 Various factors that impinge upon the engineer’s physical working environment have
been highlighted in this chapter. Apart from those already discussed, other physical
influences include:
• workplace layout and the cleanliness and general tidiness of the workplace (e.g.
storage facilities for tools, manuals and information, a means of checking that all
tools have been retrieved from the aircraft, etc.);
• the proper provision and use of safety equipment and signage (such as non-slip
surfaces, safety harnesses, etc.);
• the storage and use of toxic chemical and fluids (as distinct from fumes) (e.g.
avoiding confusion between similar looking canisters and containers by clear
labelling or storage in different locations, etc.).
Please refer to Photograph F in Appendix A.
7.2 To some extent, some or all of the factors associated with the engineer’s workplace
may affect his ability to work safely and efficiently. JAR 145.25(c) - Facility
Requirements states:
“The working environment must be appropriate for the task carried out
and in particular special requirements observed. Unless otherwise
dictated by the particular task environment, the working environment
must be such that the effectiveness of personnel is not impaired.”
7.3 This is expanded upon in AMC 145.25(c).

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7.4 The working environment comprises the physical environment encapsulated in this
chapter, the social environment described in Chapter 3 and the tasks that need to be
carried out (examined in the next chapter). This is shown in Figure 20. Each of these
three components of the working environment interact, for example:
• engineers are trained to perform various tasks;
• successful task execution requires a suitable physical environment;
• an unsuitable or unpleasant physical environment is likely to be de-motivating.

(individual and team
responsibility, motivation,
culture, management,
supervision, leadership, etc.)

Physical Environment Tasks

(noise, illumination, fumes, (physical work, repetitive
climate, temperature, motion, tasks, etc.)
confined spaces, workplace
layout, cleanliness, etc.)

Working Environment

Figure 20 Components of the ‘working environment’

7.5 Aircraft maintenance engineering requires all three components of the working
environment to be managed carefully in order to achieve a safe and efficient system
7.6 It is important to recognise that engineers are typically highly professional and
pragmatic in their outlook, and generally attempt to do the best work possible
regardless of their working environment. Good maintenance organisations do their
best to support this dedication by providing the necessary conditions for safe and
efficient work.
Further Reading:
a) JAR145.25(c) and JAR145 AMC145.25 (c)
b) Maddox M.E. (Ed.) (1998) Human Factors Guide for Aviation Maintenance 3.0.
Washington DC: Federal Aviation Administration/Office of Aviation Medicine -
Chapters 3 and 5. Available from http://hfskyway.faa.gov
c) NTSB (1994) Special Investigation Report 94/02. Northwest Airlines, B747,
N637US, New Tokyo International Airport, Narita, Japan.

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Chapter 6 Tasks

Licensed aircraft engineering is a specialist occupation undertaken by men and

women who have received appropriate training. The possible paths into the
profession are shown in Figure 21.

‘Self-Starter’ Route ‘Ab-initio’ Route

5 years on-the-job Choose to specialise

experience as an in A&C or Avionics
aircraft mechanic,
specialising in A&C
2 years on approved
or Avionics during
(JAR 147) aircraft
this time
maintenance course

JAR 66
examination to
become a certifying
(licensed) engineer

Figure 21 Routes to becoming a Licensed Aircraft Engineer

As a self starter, training is obtained mainly on-the-job, whereas an approved course

is largely classroom-based with a condensed on-the-job element. Given the varied
nature of the maintenance tasks in aircraft maintenance, few engineers are ‘jacks of
all trades’. Most engineers opt to specialise in the tasks they carry out, either as an
Airframe and Powerplant specialist (known as A&C in UK), or as an Electrical and
Avionics specialist.
When working within an aircraft maintenance organisation, an engineer will also be
sent on ‘type courses’. These courses provide the engineer with requisite skills and
knowledge to carry out tasks on specific aircraft, engines or aircraft systems.
The rest of this chapter examines the nature of the tasks that aircraft maintenance
engineers carry out, looking at the physical work, repetitive tasks, visual inspection
and the complex systems that they work on.

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1 Physical Work

1.1 Planning
1.1.1 Blindly starting a task without planning how best to do it is almost certainly the best
way to invite problems. Before commencing a task, an individual engineer,
engineering team or planner should ask themselves a number of questions. These
may include:
• Do I/we know exactly what the task is that has to be done?
• Are the resources available to do it effectively (safely, accurately and within the
time permitted)? Where resources include:
• personnel;
• equipment/spares;
• documentation, information and guidance;
• facilities such as hangar space, lighting, etc.
• Do I/we have the skills and proficiency necessary to complete the task?
Please refer to Photograph G in Appendix A.
1.1.2 Information about specific tasks should be detailed on job cards or task sheets.
These will indicate the task (e.g. checks or inspection, repair, replacement, overhaul)
and often further details to aid the engineer (such as maintenance manual references,
part numbers, etc.).

If the engineer is in any doubt what needs to be done, written guidance material is the best
resource. Colleagues may unintentionally give incorrect or imprecise direction (the
exception to this is discussing problems that arise that are not covered in the guidance

1.1.3 It is generally the shift supervisor’s job to ensure that the resources are available for
his staff to carry out their tasks. As noted in Chapter 3, Section 2 (‘Time Pressure and
Deadlines’), it is likely that, within a shift or a team, various sub-tasks are allocated to
individuals by the supervisor. Alternatively, he may encourage a team to take
ownership of the tasks that need to be completed, giving them the discretion to
manage a package of work (as noted in Chapter 3, Section 6 (‘Team Working’). Exactly
‘who does what’ is likely to be based on factors such as individuals’ specialisation (i.e.
A&C or avionics) and their experience with the task.
1.1.4 Although management have a responsibility to ensure that their engineers have
suitable training, at the end of the day, it is up to the individual engineer to decide
whether he has the necessary skills and has the proficiency and experience to do
what he has been asked to do. He should not be afraid to voice any misgivings,
although it is recognised that peer and management pressure may make this difficult.

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1.2 Physical Tasks

1.2.1 Aircraft maintenance engineering is a relatively active occupation. Regardless of the
job being done, most tasks tend to have elements of fine motor control, requiring
precision, as well as activities requiring strength and gross manipulation.
1.2.2 From a biomechanical perspective, the human body is a series of physical links
(bones) connected at certain points (joints) that allow various movements. Muscles
provide the motive force for all movements, both fine and gross. This is known as the
musculoskeletal system. The force that can be applied in any given posture is
dependent on the strength available from muscles and the mechanical advantage
provided by the relative positions of the load, muscle connections, and joints.

As an engineer gets older, the musculoskeletal system stiffens and muscles become
weaker. Injuries become more likely and take longer to heal. Staying in shape will minimise
the effects of ageing, but they still occur.

1.2.3 It is important that maintenance tasks on aircraft are within the physical limitations of
aircraft maintenance engineers. Boeing use a computerised tool1, based on human
performance data (body sizes, strengths, leverages, pivots, etc.), to ensure that
modern aircraft are designed such that the majority of maintenance engineers will be
able to access aircraft equipment, apply the necessary strength to loosen or tighten
objects, etc. (i.e. designed for ease of maintainability).
1.2.4 Clearly we are all different in terms of physical stature and strength and as a
consequence, our physical limitations vary. Attempting to lift a heavy object which is
beyond our physical capabilities is likely to lead to injury. The use of tools generally
make tasks easier, and in some situations, may make a task achievable that was
hitherto outside our physical powers (e.g. lifting an aircraft panel with the aid of a
1.2.5 As noted in Chapter 4, Section 5 (‘Fatigue’), physical work over a period of time will
result in fatigue. This is normally not a problem if there is adequate rest and recovery
time between work periods. It can, however, become a problem if the body is not
allowed to recover, possibly leading to illness or injuries. Hence, engineers should try
to take their allocated breaks.

Missing a break in an effort to get a job done within a certain time frame can be
counterproductive, as fatigue diminishes motor skills, perception, awareness and
standards. As a consequence, work may slow and mistakes may occur that need to be

1.2.6 As discussed at some length in Chapter 4, Section 1 (‘Day-to-Day Fitness and

Health’), it is very important that engineers should try to ensure that their physical
fitness is good enough for the type of tasks which they normally do.

1. Rankin, W. (1999) Human Factors Design for Maintainability. Conference in Quality in Commercial Aviation. Dallas. USA.

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Further Reading:
a) Maddox, M.E. (Ed.) (1998) Human Factors Guide for Aviation Maintenance 3.0.
Washington DC: Federal Aviation Administration/Office of Aviation Medicine -
Chapter 1. Available from http://hfskyway.faa.gov
b) Sanders, M.S., McCormick, E.J. (1993) Human Factors in Engineering and Design.
New York: McGraw-Hill - Chapter 8: physical work and manual materials handling.

2 Repetitive Tasks

2.1 Repetitive tasks can be tedious and reduce arousal (i.e. be boring). Most of the human
factors research associated with repetitive tasks has been carried out in
manufacturing environments where workers carry out the same action many times a
minute. This does not generally apply to maintenance engineering.

Repetitive tasks in aircraft maintenance engineering typically refer to tasks that are
performed several times during a shift, or a number of times during a short time period,
e.g. in the course of a week. An example of this would be the checking life jackets on an
aircraft during daily inspections.

2.2 Some engineers may specialise in a certain aspect of maintenance, such as engines.
As a result, they may possibly carry out the same or similar tasks several times a day.
2.3 The main danger with repetitive tasks is that engineers may become so practised at
such tasks that they may cease to consult the maintenance manual, or to use job
cards. Thus, if something about a task is changed, the engineer may not be aware of
the change. Complacency is also a danger, whereby an engineer may skip steps or
fail to give due attention to steps in a procedure, especially if it is to check something
which is rarely found to be wrong, damaged or out of tolerance. This applies
particularly to visual inspection, which is covered in greater detail in the next section.

In the Aloha accident report, the NTSB raised the problem of repetitive tasks:

“The concern was expressed about what kinds of characteristics are appropriate to
consider when selecting persons to perform an obviously tedious, repetitive task such as a
protracted NDI inspection. Inspectors normally come up through the seniority ranks. If they
have the desire, knowledge and skills, they bid on the position and are selected for the
inspector job on that basis. However, to ask a technically knowledgeable person to perform
an obviously tedious and exceedingly boring task, rather than to have him supervise the
quality of the task, may not be an appropriate use of personnel…”

2.4 Making assumptions along the lines of ‘Oh I’ve done that job dozens of times!’ can
occur even if a task has not been undertaken for some time. It is always advisable to
be wary of changes to procedures or parts, remembering that ‘familiarity breeds
Further Reading:
a) NTSB (1989) Aircraft Accident Report--Aloha Airlines, Flight 243, Boeing 737-200,
N73711, near Maui, Hawaii, April 28, 1988. NTSB/AAR-89/03

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3 Visual Inspection

3.1 Visual inspection is one of the primary methods employed during maintenance to
ensure the aircraft remains in an airworthy condition.

Visual inspection can be described as the process of using the eye, alone or in conjunction
with various aids to examine and evaluate the condition of systems or components of an

3.2 Aircraft maintenance engineers may use magnifiers and borescopes to enhance their
visual capabilities. The engineer may accompany his visual inspection by examining
the element using his other senses (touch, hearing, smell, etc.). He may also
manipulate the element being inspected to make further judgements about its
condition. For instance, he might feel a surface for unevenness, or push against it to
look for any unanticipated movement.
3.3 As highlighted in Chapter 2, Section 2 (“Vision and the Aircraft Maintenance
Engineer”), good eyesight is of prime importance in visual inspection, and it was
noted that the UK CAA have provided some guidance on eyesight in AWN47.
Amongst other things, this calls for glasses or contact lenses to be used where
prescribed and regular eyesight checks to be made.
3.4 Visual inspection is often the principal method used to identify degradation or defect
in systems or components of aircraft. Although the engineer’s vision is important, he
also has to make judgements about what he sees. To do this, he brings to bear
training, experience and common sense. Thus, reliable visual inspection requires that
the engineer first sees the defect and then actually recognises that it is a defect. Of
course, experience comes with practice, but telltale signs to look for can be passed
on by more experienced colleagues.
3.5 Please refer to Photograph H in Appendix A.

Information such as technical bulletins are important as they prime the inspector of known
and potential defects and he should keep abreast of these. For example, blue staining on
an aircraft fuselage may be considered insignificant at first sight, but information from a
Technical Bulletin of ‘blue ice’ and external toilet leaks may make the engineer suspicious
of a more serious problem

3.6 There are various steps that an engineer can take to help him carry out a reliable visual
inspection. The engineer should:
• ensure that he understands the area, component or system he has been asked to
inspect (e.g. as specified on the work card);
• locate the corresponding area, component or system on the aircraft itself;
• make sure the environment is conducive to the visual inspection task (considering
factors described in Chapter 5 - “Physical Environment”, such as lighting, access,
• conduct a systematic visual search, moving his eyes carefully in a set pattern so
that all parts are inspected;
• examine thoroughly any potential degradation or defect that is seen and decide
whether it constitutes a problem;

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• record any problem that is found and continue the search a few steps prior to
where he left off.
3.7 Visual inspection requires a considerable amount of concentration. Long spells of
continuous inspection can be tedious and result in low arousal. An engineer’s low
arousal or lack of motivation can contribute to a failure to spot a potential problem or
a failure in recognising a defect during visual inspection. The effects are potentially
worse when an inspector has a very low expectation of finding a defect, e.g. on a new
3.8 Engineers may find it beneficial to take short breaks between discrete visual
inspection tasks, such as at a particular system component, frame, lap joint, etc. This
is much better than pausing midway through an inspection.

The Aloha accident highlights what can happen when visual inspection is poor. The
accident report included two findings that suggest visual inspection was one of the main
contributors to the accident:

• “There are human factors issues associated with visual and non-destructive inspection
which can degrade inspector performance to the extent that theoretically detectable
damage is overlooked.”

• “Aloha Airlines management failed to recognise the human performance factors of

inspection and to fully motivate and focus their inspector force toward the critical nature
of lap joint inspection, corrosion control and crack detection…..”

3.9 Finally, non-destructive inspection (NDI) includes an element of visual inspection, but
usually permits detection of defects below visual thresholds. Various specialist tools
are used for this purpose, such as the use of eddy currents and fluorescent penetrant
inspection (FPI).
Further Reading:
a) FAA (1993) Human Reliability in Aircraft Inspection. FAA/AAM Human Factors in
Aviation Maintenance and Inspection Research Phase II Report, Chapter 5.
Available from http://hfskyway.faa.gov
b) Drury, C. (1995) FAA/AAM Human Factors in Aviation Maintenance and Inspection
Research Phase V Report, Chapter 9. Support of the FAA/AANC Visual Inspection
Research Program (VIRP). Available from http://hfskyway.faa.gov
c) Drury, C.(1996) Support of inspection research at the FAA Technical Centre and
Sandia National Laboratories. FAA/AAM Human Factors in Aviation Maintenance
and Inspection Research Phase VI Report, Chapter 10. Available from http://
d) Drury, C. (1999) Human Factors Good Practices in Fluorescent Penetrant
Inspection. FAA. Available from http://hfskyway.faa.gov
e) NTSB (1989) Aircraft Accident Report--Aloha Airlines, Flight 243, Boeing 737-200,
N73711, near Maui, Hawaii, April 28, 1988. NTSB/AAR-89/03

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4 Complex Systems

4.1 All large modern aircraft can be described as complex systems. Within these aircraft,
there are a myriad of separate systems, many of which themselves may be
considered complex, e.g. flying controls, landing gear, air conditioning, flight
management computers. Table 4 gives an example of the breadth of complexity in
aircraft systems.

Any complex system can be thought of as having a wide variety of inputs. The system
typically performs complex modifications on these inputs or the inputs trigger complex
responses. There may be a single output, or many distributed outputs from the system.

4.2 The purpose, composition and function of a simple system is usually easily
understood by an aircraft maintenance engineer. In other words, the system is
transparent to him. Fault finding and diagnosis should be relatively simple with such
systems (although appropriate manuals etc. should be referred to where necessary).

Table 4 Example of increasing complexity - the aileron system


Simple aileron Direct connection from control column to control surface; direct

Servo tab Direct connection from control column to servo tab; aerodynamic
aileron movement of surface.

Powered Connection from control column to servo valve via input; hydraulic
aileron movement of surface; feedback mechanism; position indication.

Powered As above but with interface to spoiler input system to provide additional
aileron / roll roll capability.

Fly-by-wire No connection from control column to surface. Electrical command

aileron system signal to electro-hydraulic servo valve on actuator; signal modified and
limited by intermediate influence of flight control computer.

4.3 With a complex system, it should still be clear to an aircraft maintenance engineer
what the system’s purpose is. However, its composition and function may be harder
to conceptualise - it is opaque to the engineer.
4.4 To maintain such complex systems, it is likely that the engineer will need to have
carried out some form of system-specific training which would have furnished him
with an understanding of how it works (and how it can fail) and what it is made up of
(and how components can fail). It is important that the engineer understands enough
about the overall functioning of a large, complex aircraft, but not so much that he is
overwhelmed by its complexity. Thus, system-specific training must achieve the
correct balance between detailed system knowledge and analytical troubleshooting

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4.5 With complex systems within aircraft, written procedures and reference material
become an even more important source of guidance than with simple systems. They
may describe comprehensively the method of performing maintenance tasks, such
as inspections, adjustments and tests. They may describe the relationship of one
system to other systems and often, most importantly, provide cautions or bring
attention to specific areas or components. It is important to follow the procedures to
the letter, since deviations from procedures may have implication on other parts of
the system of which the engineer may be unaware.

When working with complex systems, it is important that the aircraft maintenance
engineer makes reference to appropriate guidance material. This typically breaks down the
system conceptually or physically, making it easier to understand and work on.

4.6 In modern aircraft, it is likely that the expertise to maintain a complex system may be
distributed among individual engineers. Thus, avionics engineers and A&C engineers
may need to work in concert to examine completely a system that has an interface to
the pilot in the cockpit (such as the undercarriage controls and indications).
4.7 A single modern aircraft is complex enough, but many engineers are qualified on
several types and variants of aircraft. This will usually mean that he has less
opportunity to become familiar with one type, making it even more important that he
sticks to the prescribed procedures and refers to the reference manual wherever
necessary. There is a particular vulnerability where tasks are very similar between a
number of different aircraft (e.g. spoiler systems on the A320, B757 and B7671), and
may be more easily confused if no reference is made to the manual.

1. AAIB A320 incident, London Gatwick Airport, August 26, 1993. AAIB report 2/95

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Chapter 7 Communication

Good communication is important in every industry. In aircraft maintenance

engineering, it is vital. Communication, or more often a breakdown in communication,
is often cited as a contributor to aviation incidents and accidents. It is for this very
reason that it has its own section in the JAR66 Module 9 for Human Factors. This
chapter examines the various aspects of communication that affect the aircraft
maintenance engineer.

Communication is defined in the Penguin Dictionary of Psychology as:

“The transmission of something from one location to another. The ‘thing’ that is
transmitted may be a message, a signal, a meaning, etc. In order to have communication
both the transmitter and the receiver must share a common code, so that the meaning or
information contained in the message may be interpreted without error”.

Source: Reber, A.S., 19951

1 Within and Between Teams

As noted in previous chapters, aircraft maintenance engineers often work as teams.

Individuals within teams exchange information and need to receive instructions,
guidance, etc. Moreover, one team will have to pass on tasks to another team at shift
handover. An engineer needs a good understanding of the various processes of
communication, as without this, it is impossible to appreciate how communication
can go wrong.
1.1 Modes of Communication
1.1.1 We are communicating almost constantly, whether consciously or otherwise. An
aircraft maintenance engineer might regularly communicate:
• information;
• ideas;
• feelings;
• attitudes and beliefs
1.1.2 As the sender of a message, he will typically expect some kind of response from the
person he is communicating with (the recipient), which could range from a simple
acknowledgement that his message has been received (and hopefully understood),
to a considered and detailed reply. The response constitutes feedback.

1. Reber, A.S. (1995) Dictionary of Psychology (2nd edition). London: Penguin.

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1.1.3 As can be seen in the above definition, communication can be:

• verbal/spoken - e.g. a single word, a phrase or sentence, a grunt;
• written/textual - e.g. printed words and/or numbers on paper or on a screen, hand
written notes;
• non-verbal -
• graphic - e.g. pictures, diagrams, hand drawn sketches, indications on a
cockpit instrument;
• symbolic - e.g. ‘thumbs up’, wave of the hand, nod of the head;
• body language - e.g. facial expressions, touch such as a pat on the back,
1.2 Verbal and Written Communication
1.2.1 Generally speaking, verbal and written communication are purposeful. For a spoken
or written message to be understood, the sender has to make sure that the receiver:
• is using the same channel of communication;
• recognises and understands his language;
• is able to make sense of the message’s meaning;
1.2.2 The channel of communication is the medium used to convey the message. For
spoken communication, this might be face-to-face, or via the telephone. Written
messages might be notes, memos, documents or e-mails.
1.2.3 In the UK it is expected that aircraft maintenance engineers will communicate in
English. However, it is also vital that the message coding used by the sender is
appreciated by the recipient so that he can decode the message accurately. This
means that engineers must have a similar knowledge of technical language, jargon
and acronyms.
1.2.4 Assuming the channel and language used are compatible, to extract meaning, the
engineer has to understand the content of the message. This means that it has to be
clear and unambiguous. The message must also be appropriate to the context of the
workplace and preferably be compatible with the receiver’s expectations. Where any
ambiguity exists, the engineer must seek clarification.
1.3 Non-verbal Communication
1.3.1 Non-verbal communication can accompany verbal communication, such as a smile
during a face-to-face chat. It can also occur independently, for instance a colleague
may pass on his ideas by using a sketch rather than the use of words. It can also be
used when verbal communication is impossible, such as a nod of the head in a noisy
1.3.2 Non-verbal communication is also the predominant manner by which systems
communicate their status. For instance, most displays in the aircraft cockpit present
their information graphically.
1.3.3 Body language can be very subtle, but often quite powerful. For example, the
message “No” accompanied by a smile will be interpreted quite differently from the
same word said whilst the sender scowls.

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1.4 Communication Within Teams

1.4.1 Individual aircraft maintenance engineers need to communicate:
• before starting a task - to find out what to do;
• during a task - to discuss work in progress, ask colleagues questions, confirm
actions or intentions, or to ensure that others are informed of the maintenance
state at any particular time;
• at the end of a task - to report its completion and highlight any problems.
1.4.2 Spoken communication makes up a large proportion of day-to-day communication
within teams in aircraft maintenance. It relies both on clear transmission of the
message (i.e. not mumbled or obscured by background noise) and the ability of the
recipient of the message to hear it (i.e. active listening followed by accurate
interpretation of the message). Good communication within a team helps to maintain
group cohesion.

Spoken messages provide considerable flexibility and informality to express work-related

matters when necessary. The key to such communication is to use words effectively and
obtain feedback to make sure your message has been heard and understood.

1.4.3 It is much less common for individuals within teams to use written communication.
They would however be expected to obtain pertinent written information
communicated by service bulletins and work cards and to complete documentation
associated with a task.
1.5 Communication Between Teams
1.5.1 Communication between teams is critical in aircraft maintenance engineering. It is the
means by which one team passes on tasks to another team. This usually occurs at
shift handover. The information conveyed will include:
• tasks that have been completed;
• tasks in progress, their status, any problems encountered, etc.;
• tasks to be carried out;
• general company and technical information.
1.5.2 Communication between teams will involve passing on written reports of tasks from
one shift supervisor to another. Ideally, this should be backed up by spoken details
passed between supervisors and, where appropriate, individual engineers. This
means that, wherever necessary, outgoing engineers personally brief their incoming
colleagues. The written reports (maintenance cards, procedures, work orders, logs,
etc.) and warning flags / placards provide a record of work completed and work yet to
be completed - in other words, they provide traceability (see Section 2 below).
Furthermore, information communicated at shift handover ensures good continuity.
It is important that handovers are not rushed, so as to minimise omissions.
1.6 Communication Problems
1.6.1 There are two main ways in which communication can cause problems. These are
lack of communication and poor communication. The former is characterised by
the engineer who forgets to pass on pertinent information to a colleague, or when a
written message is mislaid. The latter is typified by the engineer who does not make
it clear what he needs to know and consequently receives inappropriate information,
or a written report in barely legible handwriting. Both problems can lead to
subsequent human error.

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1.6.2 Communication also goes wrong when one of the parties involved makes some kind
of assumption. The sender of a message may assume that the receiver understands
the terms he has used. The receiver of a message may assume that the message
means one thing when in fact he has misinterpreted it. Assumptions may be based
on context and expectations, which have already been mentioned in this chapter.
Problems with assumptions can be minimised if messages are unambiguous and
proper feedback is given.

Basic rules of thumb to help aircraft maintenance engineers minimise poor communication

• think about what you want to say before speaking or writing;

• speak or write clearly;
• listen or read carefully;
• seek clarification wherever necessary.

Further Reading:
a) Maddox, M.E. (Ed.) (1998) Human Factors Guide for Aviation Maintenance 3.0.
Washington DC: Federal Aviation Administration/Office of Aviation Medicine -
Chapter 13. Available from http://hfskyway.faa.gov
b) Sian, B. and Robertson, M. (1998) Maintenance Resource Management
Handbook. Available from http://hfskyway.faa.gov

2 Work Logging and Recording

2.1 This is one of the most critical aspects of communication within aviation
maintenance, since inadequate logging or recording of work has been cited as a
contributor to several incidents.

In the B737 double engine oil loss incident in February 1995, for instance, one of the AAIB
conclusions was:

“…the Line Engineer…had not made a written statement or annotation on a work stage
sheet to show where he had got to in the inspections”.

The reason for this was because he had intended completing the job himself and,
therefore, did not consider that detailed work logging was necessary. However, this
contributed towards the incident in that:

“the Night Base Maintenance Controller accepted the tasks on a verbal handover [and] he
did not fully appreciate what had been done and what remained to be done”.

Source: AAIB, 19961

2.2 Even if engineers think that they are going to complete a job, it is always necessary
to keep the record of work up-to-date just in case the job has to be handed over. This
may not necessarily be as a result of a shift change, but might be due to a rest break,
illness, the need to move to another (possibly more urgent) task, etc.

1. AAIB (1996) Report on the incident to a Boeing 737-400, G-OBMM near Daventry on 25 February 1995. Aircraft Accident
Report 3/96.

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2.3 The exact manner in which work should be logged tends to be prescribed by company
procedures. It is usually recorded in written form. However, there is no logical reason
why symbols and pictures should not also be used to record work or problems,
especially when used for handovers. There are many cases where it may be clearer
to draw a diagram rather than to try to explain something in words (i.e. ‘a picture is
worth a thousand words’).
2.4 The key aspects of work logging and recording are captured in the CAA’s
Airworthiness Notice No. 3 (AWN3)1. This states:
“In relation to work carried out on an aircraft, it is the duty of all persons
to whom this Notice applies to ensure that an adequate record of the
work carried out is maintained. This is particularly important where such
work carries on beyond a working period or shift, or is handed over from
one person to another. The work accomplished, particularly if only
disassembly or disturbance of components or aircraft systems, should be
recorded as the work progresses or prior to undertaking a disassociated
task. In any event, records should be completed no later than the end of
the work period or shift of the individual undertaking the work. Such
records should include ‘open’ entries to reflect the remaining actions
necessary to restore the aircraft to a serviceable condition prior to release.
In the case of complex tasks which are undertaken frequently,
consideration should be given to the use of pre-planned stage sheets to
assist in the control, management and recording of these tasks. Where
such sheets are used, care must be taken to ensure that they accurately
reflect the current requirements and recommendations of the
manufacturer and that all key stages, inspections, or replacements are
2.5 New technology is likely to help engineers to record work more easily and effectively
in the future. ICAO Digest No.12: “Human Factors in Aircraft Maintenance and
Inspection”2, refers to hand-held computers and an Integrated Maintenance
Information System (IMIS). It points out that these devices are likely to encourage the
prompt and accurate recording of maintenance tasks.
2.6 Modern technology is also being implemented to improve the transfer of information
in maintenance manuals to worksheets and workcards. These help to communicate
pertinent information to engineers in an accessible and useable format. A contributory
factor in the B737 double engine oil loss incident was that the information which
should have prompted the engineer to carry out a post-inspection idle engine run to
check for leaks was in the maintenance manual but not carried over to the task cards.
Further Reading:
a) CAA (1999) CAP455: Airworthiness Notices. AWN3. UK Civil Aviation Authority.
b) Human Factors Digest No. 12 (1995) Human Factors in Aircraft Maintenance and
Inspection. (ICAO Circular 253)
c) FAA/AAM (1993) Human Factors in Aviation Maintenance and Inspection Research
Phase III Report - Chapter 7: Design of Workcards. Available from http://
d) AAIB (1996) Report on the incident to a B737-400, G-OBMM near Daventry on 23
February 1995. Aircraft Accident Report 3/96.

1. CAA (1999) CAP455: Airworthiness Notices. AWN3. UK Civil Aviation Authority.

2. Human Factors Digest No. 12 (1995) Human Factors in Aircraft Maintenance and Inspection. (ICAO Circular 253).

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3 Keeping Up-to-Date, Currency

3.1 As discussed in Chapter 6, aircraft maintenance engineers undertake an approved

course to obtain the knowledge and basic skills to enter the profession. This training
is followed by instruction in more specific areas, such as maintenance of individual
aircraft and specific systems (as discussed in Chapter 6, Section 4 on “Complex
Systems”). However, the aviation industry is dynamic: operators change their aircraft,
new aircraft types and variants are introduced, new aircraft maintenance practices are
introduced. As a consequence, the engineer needs to keep his knowledge and skills
3.2 To maintain his currency, he must keep abreast of pertinent information relating to:
• new aircraft types or variants;
• new technologies and new aircraft systems;
• new tools and maintenance practices;
• modifications to current aircraft and systems he works on;
• revised maintenance procedures and practices.
Engineers are likely to keep up-to-date by:
• undertaking update courses;
• reading briefing material, memos and bulletins;
• studying maintenance manual amendments
3.3 Responsibility for maintaining currency lies with both the individual engineer and the
maintenance organisation for which he works. The engineer should make it his
business to keep up-to-date with changes in his profession (remembering that
making assumptions can be dangerous). The organisation should provide the
appropriate training and allow their staff time to undertake the training before working
on a new aircraft type or variant. It should also make written information easily
accessible to engineers and encourage them to read it. It is, of course, vital that those
producing the information make it easy for engineers to understand (i.e. avoid

Anecdotal evidence describes a case where a certain maintenance procedure was

“proscribed” (i.e. prohibited) in a service bulletin. The technician reading this concluded
that the procedure was “prescribed” (i.e. defined, laid down) and proceeded to perform
the forbidden action.

3.4 From a human factors point of view, small changes to the technology or procedures
concerning existing aircraft carry potentially the greatest risk. These do not usually
warrant formal training and may merely be minor changes to the maintenance
manual. Although there should be mechanisms in place to record all such changes,
this presumes that the engineer will consult the updates. It is part of the engineer’s
individual responsibility to maintain his currency.

4 Dissemination of Information

4.1 As highlighted in the previous section, both the individual engineer and the
organisation in which he works have a shared responsibility to keep abreast of new
information. Good dissemination of information within an organisation forms part of

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its safety culture (Chapter 3, section 5). Typically, the maintenance organisation will
be the sender and the individual engineer will be the recipient.
4.2 It was noted in Chapter 6, Section 1.1 “Planning”, that an aircraft maintenance
engineer or team of engineers need to plan the way work will be performed. Part of
this process should be checking that all information relating to the task has been
gathered and understood. This includes checking to see if there is any information
highlighting a change associated with the task (e.g. the way something should be
done, the tools to be used, the components or parts involved)

It is imperative that engineers working remotely from the engineering base (e.g. on the
line) familiarise themselves with new information (on notice boards, in maintenance
manuals, etc.) on a regular basis.

4.3 There should normally be someone within the maintenance organisation with the
responsibility for disseminating information. Supervisors can play an important role by
ensuring that the engineers within their team have seen and understood any
communicated information.

Poor dissemination of information was judged to have been a contributory factor to the
Eastern Airlines accident in 1983. The NTSB accident report stated:

“On May 17, 1983, Eastern Air Lines issued a revised work card 7204 [master chip detector
installation procedures, including the fitment of O-ring seals]. … the material was posted
and all mechanics were expected to comply with the guidance. However, there was no
supervisory follow-up to insure that mechanics and foremen were incorporating the
training material into the work requirements… Use of binders and bulletin boards is not an
effective means of controlling the dissemination of important work procedures, especially
when there is no accountability system in place to enable supervisors to ensure that all
mechanics had seen the applicable training and procedural information.”

Source: NTSB, 19941

4.4 Communication is an active process whereby both the organisation and engineer
have to play their part.

1. NTSB (1994) Accident Report. Eastern Airlines, Lockheed L-1011, N334EA, Miami, Florida, May 5 1983. NTSB/AAR-84/04.

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Chapter 8 Human Error

It has long been acknowledged that human performance is at times imperfect. Nearly
two thousand years ago, the Roman philosopher Cicero cautioned “It is the nature of
man to err”. It is an unequivocal fact that whenever men and women are involved in
an activity, human error will occur at some point.

In his book “Human Error”, Professor James Reason defines error as follows:

“Error will be taken as a generic term to encompass all those occasions in which a planned
sequence of mental or physical activities fails to achieve its intended outcome, and when
these failures cannot be attributed to the intervention of some chance agency”.

Source: Reason, 19901

It is clear that aircraft maintenance engineering depends on the competence of
engineers. Many of the examples presented in Chapter 1 “Incidents Attributable to
Human Factors / Human Error” and throughout the rest of this document highlight
errors that aircraft maintenance engineers have made which have contributed to
aircraft incidents or accidents.
In the past, aircraft components and systems were relatively unreliable. Modern
aircraft by comparison are designed and manufactured to be highly reliable. As a
consequence, it is more common nowadays to hear that an aviation incident or
accident has been caused by “human error”.
The following quotation2 illustrates how aircraft maintenance engineers play a key
role in keeping modern aircraft reliable:
“Because civil aircraft are designed to fly safely for unlimited time
provided defects are detected and repaired, safety becomes a matter of
detection and repair rather than one of aircraft structure failure. In an ideal
system, all defects which could affect flight safety will have been
predicted in advance, located positively before they become dangerous,
and eliminated by effective repair. In one sense, then, we have changed
the safety system from one of physical defects in aircraft to one of errors
in complex human-centred systems”
The rest of this chapter examines some of the various ways in which human error has
been conceptualised. It then considers the likely types of error that occur during
aircraft maintenance and the implications if these errors are not spotted and
corrected. Finally, means of managing human error in aircraft maintenance are

1. Reason, J.T. (1990) Human Error. New York: Cambridge University Press.
2. Drury, C.G. (1991) Errors in Aviation Maintenance: Taxonomy and Control. In: Proceedings of the Human Factors Society
35th Annual Meeting, pp. 42-46. Available from http://hfskyway.faa.gov

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Further Reading:
a) Reason, J.T. (1990) Human Error. New York: Cambridge University Press.
b) Maddox, M.E. (Ed.) (1998) Human Factors Guide for Aviation Maintenance 3.0.
Washington DC: Federal Aviation Administration/Office of Aviation Medicine -
Chapter 14: Human Error. Available from http://hfskyway.faa.gov
c) Reason, J.T. (1997) Managing the Risks of Organisational Accidents. Aldershot:
d) Human Factors Digest No. 12: (1995) Human Factors in Aircraft Maintenance and
Inspection (ICAO Circular 253)

1 Error Models and Theories

To appreciate the types of error that it is possible to make, researchers have looked
at human error in a number of ways and proposed various models and theories. These
attempt to capture the nature of the error and its characteristics. To illustrate this, the
following models and theories will be briefly highlighted:
• design- versus operator-induced errors;
• variable versus constant errors;
• reversible versus irreversible errors;
• slips, lapses and mistakes;
• skill-, rule- and knowledge-based behaviours and associated errors;
• the ‘Swiss Cheese Model’.
1.1 Design-Versus Operator-Induced Errors
1.1.1 In aviation, emphasis is often placed upon the error(s) of the front line operators, who
may include flight crew, air traffic controllers and aircraft maintenance engineers.
1.1.2 However, errors may have been made before an aircraft ever leaves the ground by
aircraft designers. This may mean that, even if an aircraft is maintained and flown as
it is designed to be, a flaw in its original design may lead to operational safety being
compromised. Alternatively, flawed procedures put in place by airline, maintenance
organisation or air traffic control management may also lead to operational problems.
1.1.3 It is common to find when investigating an incident or accident that more than one
error has been made and often by more than one person. It may be that, only when
a certain combination of errors arises and error ‘defences’ breached (see the ‘Swiss
Cheese Model’) will safety be compromised.

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1.2 Variable Versus Constant Errors

1.2.1 In his book “Human Error”, Professor Reason discusses two types of human error:
variable and constant. It can be seen in Figure 22 that variable errors in (A) are
random in nature, whereas the constant errors in (B) follow some kind of consistent,
systematic (yet erroneous) pattern. The implication is that constant errors may be
predicted and therefore controlled, whereas variable errors cannot be predicted and
are much harder to deal with. If we know enough about the nature of the task, the
environment it is performed in, the mechanisms governing performance, and the
nature of the individual, we have a greater chance of predicting an error.

Figure 22 Variable versus Constant Errors.

Target patterns of 10 shots fired by two riflemen. Rifleman A’s pattern
exhibits no constant error, but large variable errors; rifleman B’s pattern
exhibit’s a large constant error but small variable errors. The latter would,
potentially, be easier to predict and to correct (e.g. by correctly aligning
the rifle sight). Chapanis, 1951

1.2.2 However, it is rare to have enough information to permit accurate predictions; we can
generally only predict along the lines of “re-assembly tasks are more likely to incur
errors than dismantling tasks”, or “an engineer is more likely to make an error at 3
a.m., after having worked 12 hours, than at 10 a.m. after having worked only 2 hours”.
It is possible to refine these predictions with more information, but there will always
be random errors or elements which cannot be predicted.
1.3 Reversible Versus Irreversible Errors
1.3.1 Another way of categorising errors is to determine whether they are reversible or
irreversible. The former can be recovered from, whereas the latter typically cannot be.
For example, if a pilot miscalculates the fuel he should carry, he may have to divert to
a closer airfield, but if he accidentally dumps his fuel, he may not have many options
open to him.
1.3.2 A well designed system or procedure should mean that errors made by aircraft
maintenance engineers are reversible. Thus, if an engineer installs a part incorrectly,
it should be spotted and corrected before the aircraft is released back to service by
supervisory procedures in place.

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1.4 Slips, Lapses and Mistakes

1.4.1 Reason highlights the notion of ‘intention’ when considering the nature of error,
asking the questions:
• Were the actions directed by some prior intention?
• Did the actions proceed as planned?
• Did they achieve their desired end?
1.4.2 Reason then suggests an error classification based upon the answers to these
questions as shown in Figure 23.

Involuntary or non-
NO intentional action
Was there a prior NO Was there intention
intention to act? in the action?
Spontaneous or
YES subsidiary action

Did the actions NO Unintentional action

proceed as planned? - slip or lapse


Did the actions NO Intentional but

achieve the desired mistaken action



Figure 23 Error types based on intention. Source: Reason, 19901

1.4.3 The most well-known of these are slips, lapses and mistakes.

Slips can be thought of as actions not carried out as intended or planned, e.g. ‘transposing
digits when copying out numbers, or misordering steps in a procedure.

Lapses are missed actions and omissions, i.e. when somebody has failed to do something
due to lapses of memory and/or attention or because they have forgotten something, e.g.
forgetting to replace an engine cowling.

Mistakes are a specific type of error brought about by a faulty plan/intention, i.e. somebody
did something believing it to be correct when it was, in fact, wrong, e.g. an error of
judgement such as mis-selection of bolts when fitting an aircraft windscreen.

1.4.4 Slips typically occur at the task execution stage, lapses at the storage (memory) stage
and mistakes at the planning stage.

1. Reason, J.T. (1990) Human Error. New York: Cambridge University Press

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1.4.5 Violations sometimes appear to be human errors, but they differ from slips, lapses
and mistakes because they are deliberate ‘illegal’ actions, i.e. somebody did
something knowing it to be against the rules (e.g. deliberately failing to follow proper
procedures). Aircraft maintenance engineers may consider that a violation is well-
intentioned, i.e. ‘cutting corners’ to get a job done on time. However, procedures
must be followed appropriately to help safeguard safety.
1.5 Skill-, Rule- and Knowledge-Based Behaviours and Associated Errors
1.5.1 The behaviour of aircraft maintenance engineers can be broken down into three
distinct categories: skill-based, rule-based and knowledge-based behaviour.

Green et al define these:

“Skill-based behaviours are those that rely on stored routines or motor programmes that
have been learned with practice and may be executed without conscious thought.

Rule-based behaviours are those for which a routine or procedure has been learned. The
components of a rule-based behaviour may comprise a set of discrete skills.

Knowledge-based behaviours are those for which no procedure has been established.
These require the [aircraft maintenance engineer] to evaluate information, and then use his
knowledge and experience to formulate a plan for dealing with the situation.”

1.5.2 Each of these behaviour types have specific errors associated with them.
1.5.3 Examples of skill-based errors are action slips, environmental capture and
reversion. Action slips as the name implies are the same as slips, i.e. an action not
carried out as intended. The example given in Figure 24 may consist of an engineer
realising he needs a certain wrench to complete a job but, because he is distracted
by a colleague, picks up another set to the wrong torque and fails to notice that he
has tightened the bolts incorrectly.

Aircraft Aircraft
Correct maintenance Wrong skill maintenance
engineer is engineer fails ERROR
decision applied
distracted to monitor

Figure 24 Example of an Action Slip

1.5.4 Environmental capture may occur when an engineer carries out a certain task very
frequently in a certain location. Thus, an engineer used to carrying out a certain
maintenance adjustment on an Airbus A300, may inadvertently carry out this
adjustment on the next A300 he works on, even if it is not required (and he has not
made a conscious decision to operate the skill).
1.5.5 Reversion can occur once a certain pattern of behaviour has been established,
primarily because it can be very difficult to abandon or unlearn it when it is no longer
appropriate. Thus, an engineer may accidentally carry out a procedure that he has
used for years, even though it has been recently revised. This is more likely to happen
when people are not concentrating or when they are in a stressful situation.

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1.5.6 Rule-based behaviour is generally fairly robust and this is why the use of procedures
and rules is emphasised in aircraft maintenance. However, errors here are related to
the use of the wrong rule or procedure. For example, an engineer may misdiagnose
a fault and thus apply the wrong procedure, thus not clearing the fault. Errors here are
also sometimes due to faulty recall of procedures. For instance, not remembering the
correct sequence when performing a procedure.
1.5.7 Errors at the knowledge-based performance level are related to incomplete or
incorrect knowledge or interpreting the situation incorrectly. An example of this might
be when an engineer attempts an unfamiliar repair task and assumes he can ‘work it
out’. Once he has set out in this way, he is likely to take more notice of things that
suggest he is succeeding in his repair, while ignoring evidence to the contrary (known
as confirmation bias).
1.6 The ‘Swiss Cheese Model’
1.6.1 In his research, Reason has highlighted the concept of ‘defences’ against human
error within an organisation, and has coined the notion of ‘defences in depth’.
Examples of defences are duplicate inspections, pilot pre-flight functional checks,
etc., which help prevent to ‘trap’ human errors, reducing the likelihood of negative
consequences. It is when these defences are weakened and breached that human
errors can result in incidents or accidents. These defences have been portrayed
diagramatically, as several slices of Swiss cheese (and hence the model has become
known as Professor Reason’s “Swiss cheese” model) (see Figure 25).

Figure 25 Reason’s Swiss Cheese Model. Source: Reason, 19901

1. Reason, J.T. (1990) Human Error. New York: Cambridge University Press.

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1.6.2 Some failures are latent, meaning that they have been made at some point in the
past and lay dormant. This may be introduced at the time an aircraft was designed or
may be associated with a management decision. Errors made by front line personnel,
such as aircraft maintenance engineers, are ‘active’ failures. The more holes in a
system’s defences, the more likely it is that errors result in incidents or accidents, but
it is only in certain circumstances, when all holes ‘line up’, that these occur. Usually,
if an error has breached the engineering defences, it reaches the flight operations
defences (e.g. in flight warning) and is detected and handled at this stage. However,
occasionally in aviation, an error can breach all the defences (e.g. a pilot ignores an in
flight warning, believing it to be a false alarm) and a catastrophic situation ensues.
1.6.3 Defences in aircraft maintenance engineering will be considered further in Section 4.

2 Types of Error in Maintenance Tasks

2.1 As aircraft maintenance engineers are human, errors in the industry are inevitable.

Any maintenance task performed on an aircraft is an opportunity for human error to be

introduced. Errors in aircraft maintenance engineering tend to take two specific forms:

i) an error that results in a specific aircraft problem that was not there before the
maintenance task was initiated;
ii) an error that results in an unwanted or unsafe condition remaining undetected
while performing a maintenance task designed to detect aircraft problems, i.e.
something is missed.

2.2 Examples of errors highlighted in (i) in the box above are incorrect installation of line-
replaceable units, failure to remove a protective cap from a hydraulic line before re-
assembly or damaging an air duct used as a foothold while gaining access to perform
a task. Examples of errors in (ii) are a structural crack unnoticed during a visual
inspection task or a faulty avionics box that remains on the aircraft because incorrect
diagnosis of the problem led to removal of the wrong box. The actual error type
responsible can be any of those highlighted in the previous section of this document.
2.3 Errors During Regular and Less Frequent Maintenance Tasks
2.3.1 A large proportion of maintenance tasks are fairly routine, such as regular, periodic
checks on aircraft. Thus, engineers will use a certain set of procedures relatively
frequently and, as noted in the previous section, slips and lapses can occur when
carrying out procedures in the busy hangar or line environment. Chapter 6, Section 2
“Repetitive Tasks” noted that engineers will often become so accustomed to doing
a regular, often repeated task, that they will dispense with written guidance
altogether. It would be unrealistic and unnecessarily time consuming to expect them
to constantly refer to familiar guidance material. However, errors may occur if they do
not keep up-to-date with any changes that occur to these frequently used procedures.
These routine tasks are also prone to complacency, environmental capture and
rule-based errors.
2.3.2 When undertaking less frequently performed tasks, there is the possibility of errors
of judgement. If the engineer does not familiarise or refamiliarise himself properly
with what needs to be done, he may mistakenly select the wrong procedure or parts.
2.4 Violation in Aircraft Maintenance
2.4.1 It is an unfortunate fact of life that violations occur in aviation maintenance. Most
stem from a genuine desire to do a good job. Seldom are they acts of vandalism or

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sabotage. However. they represent a significant threat to safety as systems are

designed assuming people will follow the procedures. There are four types of
• Routine violations;
• Situational violations;
• Optimising violations;
• Exceptional violations.
2.4.2 Routine violations are things which have become ‘the normal way of doing
something’ within the person’s work group (e.g. a maintenance team). They can
become routine for a number of reasons: engineers may believe that procedures may
be over prescriptive and violate them to simplify a task (cutting corners), to save time
and effort.
2.4.3 Situational violations occur due to the particular factors that exist at the time, such
as time pressure, high workload, unworkable procedures, inadequate tooling, poor
working conditions. These occur often when, in order to get the job done, engineers
consider that a procedure cannot be followed.
2.4.4 Optimising violations involve breaking the rules for ‘kicks’. These are often quite
unrelated to the actual task. The person just uses the opportunity to satisfy a personal
2.4.5 Exceptional violations are typified by particular tasks or operating circumstances
that make violations inevitable, no matter how well intentioned the engineer might

Examples of routine violations are not performing an engine run after a borescope
inspection (“it never leaks”), or not changing the ‘O’ seals on the engine gearbox drive pad
after a borescope inspection (“they are never damaged”).

An example of a situational violation is an incident which occurred where the door of a

B747 came open in-flight. An engineer with a tight deadline discovered that he needed a
special jig to drill off a new door torque tube. The jig was not available, so the engineer
decided to drill the holes by hand on a pillar drill. If he had complied with the maintenance
manual he could not have done the job and the aircraft would have missed the service.

An example of an optimising violation would be an engineer who has to go across the

airfield and drives there faster than permitted

2.4.6 Time pressure and high workload increase the likelihood of all types of violations
occurring. People weigh up the perceived risks against the perceived benefits,
unfortunately the actual risks can be much higher.

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2.5 Errors Due to Individual Practices and Habits

2.5.1 Where procedures allow some leeway, aircraft maintenance engineers often develop
their own strategies or preferred way of carrying out a task. Often, a ‘good’ rule or
principle is one that has been used successfully in the past. These good rules become
‘rules of thumb’ that an engineer might adopt for day-to-day use. Problems occur
when the rule or principle is wrongly applied. For example, aircraft pipe couplings are
normally right hand threads but applying this ‘normally good rule’ to an oxygen pipe
(having a different thread) could result in damage to the pipe. Also, there can be
dangers in applying rules based on previous experience if, for example, design
philosophy differs, as in the case of Airbus and Boeing. This may have been a factor
in an A320 locked spoiler incident, where subtle differences between the operation
of the spoilers on the A320 and those of the B767 (with which the engineers were
more familiar) meant that actions which would have been appropriate on the B767
were inappropriate in the case of the A320.
2.5.2 In addition, engineers may pick up some ‘bad rules’, leading to bad habits during their
working life, as a driver does after passing his driving test. An example of applying a
bad rule is the British Rail technician in the Clapham train accident who had acquired
the practice of bending back old wires rather than cutting them off and insulating
2.6 Errors Associated With Visual Inspection
There are also two particular types of error which are referred to particularly in the
context of visual inspection, namely Type 1 errors and Type 2 errors. A Type 1 error
occurs when a good item is incorrectly identified as faulty; a Type 2 error occurs when
a faulty item is missed. Type 1 errors are not a safety concern per se, except that it
means that resources are not being used most effectively, time being wasted on
further investigation of items which are not genuine faults. Type 2 errors are of most
concern since, if the fault (such as a crack) remains undetected, it can have serious
consequences (as was the case in the Aloha accident, where cracks remained
2.7 Reason’s Study of Aviation Maintenance Engineering
2.7.1 Reason analysed1 the reports of 122 maintenance incidents occurring within a major
airline over a 3 year period. He identified the main causes as being:
• Omissions (56%)
• Incorrect installation (30%)
• Wrong parts (8%)
• Other (6%)
2.7.2 It is likely that Reason’s findings are representative for the aircraft maintenance
industry as a whole. Omissions can occur for a variety of reason, such as forgetting,
deviation from a procedure (accidental or deliberate), or due to distraction. The B7372
double engine oil loss incident, in which the HP rotor drive covers were not refitted is
an example of omission. Incorrect installation is unsurprising, as there is usually only
one way in which something can be taken apart but many possible ways in which it
can be reassembled. Reason illustrates this with a simple example of a bolt and
several nuts (see Figure 26), asking the questions (a) how many ways can this be

1. Reason, J.T. (1997) Managing the Risks of Organizational Accidents. Aldershot: Ashgate.
2. AAIB (1996) Report on the incident to a Boeing 737-400, GOBMM near Daventry on 25 February 1995. Aircraft Accident
report 3/96

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disassembled? (the answer being 1) and (b) how many ways can it be reassembled?
(the answer being about 40,000, excluding errors of omission!).


Figure 26 Reason’s Bolt and Nuts Example. Source: Reason, 19971

1. Reason, J.T. (1997) Managing the Risks of Organisational Accidents. Aldershot: Ashgate.

2.7.3 In the BAC1-111 accident in June 1990, the error was fitting the wrong bolts to the
windscreen. This illustrates well the category of ‘wrong parts’.
Further Reading:
a) Ashworth, W. (1998) Error Management in a 3rd Party Repair Station. In:
Proceedings of 12th Symposium on Human Factors in Aviation Maintenance.
March 1998. Available from http://hfskyway.faa.gov

3 Implications of Errors (i.e. Accidents)

3.1 In the worst cases, human errors in aviation maintenance can and do cause aircraft
accidents. However, as portrayed in Figure 27, accidents are the observable
manifestations of error. Like an iceberg which has most of its mass beneath the water
line, the majority of errors do not result in actual accidents.



Serious Incidents
Sea level


Minor events

Figure 27 The “Iceberg Model” of Accidents

3.2 Thankfully, most errors made by aircraft maintenance engineers do not have
catastrophic results. This does not mean that this might not be the result should they
occur again.

1. AAIB (1992) Report on the accident on BAC 1-11, GBJRT over Didcot, Oxfordshire on 10 June 1990. Aircraft Accident
report 1/92.

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3.3 Errors that do not cause accidents but still cause a problem are known as incidents.
This subject was introduced at the beginning of this document in Chapter 1, Section
2 “Incidents Attributable To Human Factors / Human Error”, which gave examples of
aviation incidents relating to aircraft maintenance errors. Some incidents are more
high profile than others, such as errors causing significant in-flight events that,
fortuitously, or because of the skills of the pilot, did not become accidents. Other
incidents are more mundane and do not become serious because of defences built
into the maintenance system. However, all incidents are significant to the aircraft
maintenance industry, as they may warn of a potential future accident should the
error occur in different circumstances. As a consequence, all maintenance incidents
have to be reported to the UK Civil Aviation Authority Mandatory Occurrence
Reporting Scheme (MORS). These data are used to disclose trends and, where
necessary, implement action to reduce the likelihood or criticality of further errors. In
the UK, the Confidential Human Factors Incident Reporting Programme (CHIRP)
scheme provides an alternative reporting mechanism for individuals who want to
report safety concerns and incidents confidentially.
3.4 It is likely that the greatest proportion of errors made by aircraft maintenance
engineers are spotted almost immediately they are made and corrected. The
engineer may detect his own error, or it may be picked up by colleagues, supervisors
or quality control. In these cases, the engineer involved should (it is hoped) learn from
his error and therefore (it is hoped) be less likely to make the same error again.

It is vital that aircraft maintenance engineers learn from their own errors and from the
errors made by others in the industry. These powerful and persuasive lessons are the
positive aspects of human error.

3.5 When an error occurs in the maintenance system of an airline, the engineer who last
worked on the aircraft is usually considered to be ‘at fault’. The engineer may be
reprimanded, given remedial training or simply told not to make the same error again.
However, blame does not necessarily act as a positive force in aircraft maintenance:
it can discourage engineers from ‘coming clean’ about their errors. They may cover
up a mistake or not report an incident. It may also be unfair to blame the engineer if
the error results from a failure or weakness inherent in the system which the engineer
has accidentally discovered (for example, a latent failure such as a poor procedure
drawn up by an aircraft manufacturer - possibly an exceptional violation).
3.6 The UK Civil Aviation Authority has stressed in Airworthiness Notice No. 71 (Issue 1,
20 March 2000) that it “seeks to provide an environment in which errors may be
openly investigated in order that the contributing factors and root causes of
maintenance errors can be addressed”. To facilitate this, it is considered that an
unpremeditated or inadvertent lapse should not incur any punitive action, but a breach
of professionalism may do so (e.g. where an engineer causes deliberate harm or
damage, has been involved previously in similar lapses, attempted to hide their lapse
or part in a mishap, etc.).
Further Reading:
a) Wenner, C.L., and Drury, C.G. (1996) A Unified Incident Reporting System For
Maintenance Facilities. In: FAA Human Factors in Aviation Maintenance and
Inspection. Research Phase Report VI, Vol II. Available from http://
b) CAA (1999) CAP455: Airworthiness Notices. AWN71. UK Civil Aviation Authority.

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4 Avoiding and Managing Errors

4.1 Whilst the aircraft maintenance engineering industry should always strive towards
ensuring that errors do not occur in the first place, it will never be possible to eradicate
them totally. Therefore all maintenance organisations should aim to ‘manage’ errors.

Error management seeks to:

• prevent errors from occurring;

• eliminate or mitigate the bad effects of errors

4.2 Reason refers to the two components of error management as: (i) error containment
and (ii) error reduction.
4.3 To prevent errors from occurring, it is necessary to predict where they are most likely
to occur and then to put in place preventative measures. Incident reporting schemes
(such as MORS) do this for the industry as a whole. Within a maintenance
organisation, data on errors, incidents and accidents should be captured with a Safety
Management System (SMS), which should provide mechanisms for identifying
potential weak spots and error-prone activities or situations. Output from this should
guide local training, company procedures, the introduction of new defences, or the
modification of existing defences.
4.4 According to Reason1, error management includes measure to:
• minimise the error liability of the individual or the team;
• reduce the error vulnerability of particular tasks or task elements;
• discover, assess and then eliminate error-producing (and violation-producing)
factors within the workplace;
• diagnose organisational factors that create error-producing factors within the
individual, the team, the task or the workplace;
• enhance error detection;
• increase the error tolerance of the workplace or system;
• make latent conditions more visible to those who operate and manage the system;
• improve the organisation’s intrinsic resistance to human fallibility.
4.5 It would be very difficult to list all means by which errors might be prevented or
minimised in aircraft maintenance. In effect, the whole of this document discusses
mechanisms for this, from ensuring that individuals are fit and alert, to making sure
that the hangar lighting is adequate.

One of the things likely to be most effective in preventing error is to make sure that
engineers follow procedures. This can be effected by ensuring that the procedures are
correct and usable, that the means of presentation of the information is user friendly and
appropriate to the task and context, that engineers are encouraged to follow procedures
and not to cut corners.

4.6 Ultimately, maintenance organisations have to compromise between implementing

measures to prevent, reduce or detect errors, and making a profit. Some measures

1. Reason, J.T. (1997) Managing the Risks of Organisational Accidents. Aldershot: Ashgate.

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cost little (such as renewing light bulbs in the hangar); others cost a lot (such as
employing extra staff to spread workload). Incidents tend to result in short term error
mitigation measures but if an organisation has no incidents for a long time (or has
them but does not know about them or appreciate their significance), there is a
danger of complacency setting in and cost reduction strategies eroding the defences
against error. Reason1 refers to this as “the unrocked boat” (Figure 28).

Protection Bankruptcy

Better defences
to increased



Figure 28 The lifespan of a hypothetical organisation through the production -

protection space. Reason, 1997

4.7 It is important that organisations balance profit and costs, and try to ensure that the
defences which are put in place are the most cost-effective in terms of trapping errors
and preventing catastrophic outcomes.
4.8 Ultimately, it is the responsibility of each and every aircraft maintenance engineer to
take every possible care in his work and be vigilant for error (see Chapter 3, Section
1). On the whole, aircraft maintenance engineers are very conscious of the
importance of their work and typically expend considerable effort to prevent injuries,
prevent damage, and to keep the aircraft they work on safe.
Further Reading:
a) Reason, J.T. (1990) Human Error. New York: Cambridge University Press.
b) Maddox, M.E. (Ed.) (1998) Human Factors Guide for Aviation Maintenance 3.0.
Washington DC: Federal Aviation Administration/Office of Aviation Medicine -
Chapter 14: Human Error. Available from http://hfskyway.faa.gov
c) Reason, J.T. (1997) Managing the Risks of Organisational Accidents. Aldershot:
d) Human Factors Digest No. 12 (1995) Human Factors in Aircraft Maintenance and
Inspection (ICAO Circular 253).
e) CAA (2001) CAP712 Safety Management Systems for Commercial Air Transport
Operations. UK Civil Aviation Authority.

1. Reason, J.T. (1997) Managing the Risks of Organisational Accidents. Aldershot: Ashgate.

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Chapter 9 Hazards In The Workplace

Hazards in the workplace tend to be a health and safety issue, relating to the
protection of individuals at work. All workplaces have hazards and aircraft
maintenance engineering is no exception. Health and safety is somewhat separate
from human factors and this chapter therefore gives only a very brief overview of the
issues relating the aircraft maintenance engineering.

1 Recognising and Avoiding Hazards

1.1 Potential Hazards in Aircraft Maintenance Engineering

1.1.1 There are may potential hazards in the aircraft maintenance industry and it is
impossible to list them all here. However, a thorough health and safety appraisal will
reveal the hazards. Physical hazards may include:
• very bright lights (e.g. from welding);
• very loud sounds (sudden or continuous);
• confined or enclosed areas;
• working at significant heights;
• noxious substances (liquids, fumes, etc.);
• excessive temperature (i.e. too cold or too hot);
• moving equipment, moving vehicles and vibration.
1.1.2 Many of these have been addressed earlier in this document (e.g. Chapter 5 “Physical
1.2 Relevant Legislation and the Maintenance Organisation’s Responsibilities
1.2.1 The UK Health and Safety Executive (HSE) have responsibility for overseeing safety
in the workplace. The Health and Safety at Work Act 1974 and accompanying
Regulations are the relevant legislation and the HSE produce publications and leaflets
summarising various aspects. The Health and Safety at Work Act 1974 places a
responsibility on employers to produce a written statement of general policy with
respect to the Health and Safety at Work of its employees. The employer is also
obliged to bring to the notice of all its employees this policy together with the
organisation and arrangements in force for carrying out that policy. Thus, in an aircraft
maintenance organisation, the health and safety policy might include statements
applicable to the organisation such as the need to:
• Carry out assessments of work including inspections to determine Health and
Safety risks;
• Provide safe working practices and procedures for plant, machinery, work
equipment, materials and substances;
• Inform employees and other persons including temporary workers of any risk;
• Provide suitable training and/or instruction to meet any Health and Safety risks;
• Develop and introduce practices and procedures to reduce risks to Health and
Safety including the provision of special protective devices and personal protective

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• Provide for the welfare of employees;

• Discuss with and consult employee representatives on Health and Safety matters.
1.2.2 Maintenance organisations should appoint someone with health and safety

In brief, a maintenance organisation has a duty under health and safety legislation to:

• identify hazards in the workplace;

• remove them where possible;
• mitigate the risks to employees.

1.2.3 If hazards cannot be removed from the workplace, employees should be made aware
that they exist and how to avoid them. This can be effected through training and
warning signs. To be effective, warnings signs must:
• clearly identify the hazard(s);
• describe the danger (i.e. electric shock, radiation, etc);
• inform employees what to do or not to do.
1.2.4 The sign must attract an engineer’s attention, it must be visible and it must be
understandable to the people it is aimed at. Additionally, in the maintenance industry,
it must be durable enough to remain effective, often for years, in areas where dust
and the elements can be present.
1.2.5 Positive recommendations are more effective than negative ones. For example, the
statement "Stay behind yellow line on floor" is better than "Do not come near this
equipment". Warning signs should contain a single word indicating the degree of risk
associated with the hazard: DANGER denotes that the hazard is immediate and could
cause grave, irreversible damage or injury. CAUTION indicates a hazard of lesser
magnitude. The sign should also detail how to avoid or manage the risk. CAUTION
signs are generally yellow and black. DANGER signs use red, black and white.
1.3 Engineer’s Individual Responsibilities
1.3.1 The legislation notes that every individual in a workplace also has health and safety

Every aircraft maintenance engineer should be aware that he can influence the safety of
those with whom he works.

1.3.2 Thus, in an aircraft maintenance organisation, the health and safety policy might
include statements applicable to engineers such as the need to:
• Take reasonable care of the health and safety of themselves and others who may
be affected by their acts or omissions at work;
• Co-operate with the maintenance organisation to ensure that statutory
requirements concerning health and safety at work are met;
• Work in accordance with any safety instruction and/or training received;
• Inform their supervisor or management of work situations that represent an
immediate or potential danger to health and safety at work and any shortcomings
in protection arrangements;

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• Not interfere intentionally or recklessly with, nor misuse, anything provided in the
interests of health and safety.
1.3.3 The attitude of an individual engineer, team or maintenance organisation (i.e.
organisational culture) can have a significant impact on health and safety.
Individuals who display an anti-authority attitude, are impulsive, or reckless are a
danger in aircraft maintenance.
1.3.4 Safety In the Working Environment
Engineers should ensure that they keep the working environment safe. Clutter,
rubbish, etc. is not only a nuisance to others, but can constitute a danger (e.g. a trip
hazard, fire hazard, etc.). In addition, engineers should be careful when working on the
line not to leave objects when a job has been completed. Foreign Object Damage
(FOD) is a risk to aircraft operating at an airfield.
1.3.5 Safety When Working On Aircraft
Before operating or working on aircraft system, an engineer should carry out
clearance checks around moveable surfaces (e.g. flying controls, landing gear, flaps,
etc.). Deactivation procedures should be followed (e.g. pull circuit breakers, isolate
valves, disconnect power, etc.). Notification of deactivation through the provision of
adequate placard in key locations is essential to inform others of system status.
1.4 Dealing With Emergencies
1.4.1 Careful handling of health and safety in the maintenance environment should serve
to minimise risks. However, should health and safety problems occur, all personnel
should know as far as reasonably practical how to deal with emergency situations.
Emergencies may include:
• An injury to oneself or to a colleague;
• A situation that is inherently dangerous, which has the potential to cause injury
(such as the escape of a noxious substance, or a fire).
1.4.2 Appropriate guidance and training should be provided by the maintenance
organisation. The organisation should also provide procedures and facilities for
dealing with emergency situations and these must be adequately communicated to
all personnel. Maintenance organisations should appoint and train one or more first

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The basic actions in an emergency are to:

• Stay calm and assess the situation

• Observe what has happened;

• Look for dangers to oneself and others;
• Never put oneself at risk.

• Make the area safe

• Protect any casualties from further danger;

• Remove the danger if it is safe to do so (i.e. switching off an electrical current
if an electrocution has occurred);
• Be aware of ones own limitations (e.g. do not fight a fire unless it is practical
to do so).

• Assess all casualties to the best of ones abilities (especially if one is a qualified first aider)
• Call for help

• Summon help from those nearby if it is safe for them to become involved;
• Call for local emergency equipment (e.g. fire extinguisher);
• Call for emergency services (ambulance or fire brigade, etc.).

• Provide assistance as far as one feels competent to.

1.4.3 Emergency drills are of great value in potentially dangerous environments. Aircraft
maintenance engineers should take part in these wherever possible. Knowledge of
what to do in an emergency can save lives.
Further Reading:
a) Maddox, M.E. (Ed.) (1998) Human Factors Guide for Aviation Maintenance 3.0.
Washington DC: Federal Aviation Administration/Office of Aviation Medicine -
Chapter 3: Workplace Safety Guidelines. Available from http://hfskyway.faa.gov

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Appendix A

Photograph A Engineer working on staging

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Photograph B Certifying engineer checking and signing for completed


Photograph C Use of artificial lighting to supplement the ambient

illumination in a hangar

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Photograph D Task lighting to facilitate internal inspection and work

Photograph E Mobile access platforms, such as a “Cherry Picker “, must be

stable in use

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Photograph F It is important that tools are close to hand and the work area
is tidy

Photograph G Referring to pertinent maintenance documentation is a key

element of planning

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Photograph H An engineer making a visual inspection of engine fan blades

22 January 2002 Appendix A Page 5